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What happens when physicians know the maximum a plan will pay for a service? Do they use that information to become better negotiators or do they automatically charge the max? A court decision could provide an answer.
A new radiosurgical methodology, the "associated targets methodology" has been developed and tested by our group for the irradiation of complex cerebral arteriovenous malformations using our treatment planning system Artemis-3D. For the treatment of the arteriovenous malformations we used 15 MV photons generated by a Saturne 43 Linac, eight additional collimators (6-20 mm in diameter), the Betti fixation seat and the Talairach stereotactic frame. The successive steps of the associated targets' methodology are: -the prescription of a peripheral minimal therapeutic effective dose corresponding to the 60-70% cumulated isodose range; -the compartmentalization of the target volume into several sub-volumes, each of them having its own isocenter, collimator, irradiation space and isocenter dose weight; -the 3-dimensional computation and graphics requirements, and dose volume analysis; -the optimization evaluation criteria taking into account the dose inside and outside of the lesion. Two treatment planning software versions of Artemis-3D exist; the first one was developed for the sitting position and later for the supine treatment position, the second version is a multi-modalities imagery radiosurgical treatment planning system based on more powerful computers. Different types of stereotactic frames have been integrated. Three-dimensional visualization, stereotactic CT imaging, and angiography can be used for the sitting or supine position. We started using this methodology in 1990, and treated 44 patients during that year. For 26 single isocenter arteriovenous malformations, the obliteration rate was 22/26 (85%). In the 18 multi-isocenters irradiation cases, the overall obliteration rate was 11/18 = 61%. An example of successfully irradiated complex arteriovenous malformation is discussed to illustrate the methodology. With this three-dimensional methodology we have improved the results obtained during the first period (1986 to 1989) of our radiosurgical practice in which we used a two dimensional planification approach.
A quality circle is a group of service providers who meet regularly to solve problems relating to the quality of their work. This is an example of bottom-up rather than top-down management which has found considerable success in the industries of the developed world. This article describes the principles which govern the operation of quality circles, the expected benefits and how best to introduce them. The problems relating to the provision of quality health care in rural areas and the potential application of the quality circle methodology are discussed.
PURPOSE/OBJECTIVES: To analyze research related to the pediatric oncology population supportive care needs from diagnosis to treatment. DATA SOURCES: Articles published from 1992-2002. DATA SYNTHESIS: 49 studies were included. All six categories of the Supportive Care Needs Framework were found, with most studies addressing one to three of the need categories. Informational (88%) and emotional (84%) needs were identified most frequently. CONCLUSIONS: No one study examined the entire range and types of supportive care needs from diagnosis to treatment. This knowledge is key to planning appropriate care and services. Future research should be directed at understanding the full constellation of needs encountered by parents during this time. Further refinement of the Supportive Care Needs Framework is required to fully define the categories of need. IMPLICATIONS FOR NURSING: Although more research is required, supportive care that focuses on informational and emotional support appears to be most important from diagnosis to treatment. Using a conceptual framework such as the Supportive Care Needs Framework provides a methodology for planning care based on needs.
"This is a methodological study concerning the family planning practices of the migrant farm-workers in the Dogankent region [of Turkey]. The workers were given health services and education about family planning methods during off-work hours. Out of the 3,022 subjects starting the study, 304 of whom were already benefiting from some kind of (traditional or modern) family planning methods: 1,393 ended up...with using effective methods...." (SUMMARY IN TUR)
When planning to implement health-related quality of life (HRQL) assessment in a multinational clinical trial, there are at least four general considerations: the natural history of the disease or condition, the characteristics of the population, the treatment under consideration, and the structure and function of the clinical trial organization. Each of these considerations must be addressed simultaneously when planning, implementing and analysing a cross-national clinical trial. There are five relevant polar components of the natural history of a given disease or condition: (1) time frame (acute versus chronic); (2) life threat (yes versus no); (3) symptomatology (present versus absent); (4) symptom expression (episodic versus constant); and (5) functional impact (present versus absent). Differences in population characteristics, (e.g., age, conditions, co-morbidity), embedded within any cross-national trial, must be addressed conceptually prior to initiating the trial, methodologically when planning implementation, and statistically after the collection of the data. In terms of treatment, issues such as adverse and positive effects and timing of effects must be considered. The methods entailed in planning, implementing and analysing HRQL data will depend upon the degree of centralization of personnel and resources within any given clinical trial. The range of possibilities runs from complete centralization, in which all planning and coordination of data collection and transmittal is done by one office, to complete decentralization, in which the work is distributed to participating sites and interested investigators. Finally, successful implementation of HRQL data collection is enhanced by heightening awareness of the importance of, and value in, assessing HRQL in clinical trials.(ABSTRACT TRUNCATED AT 250 WORDS)
This nonexperimental, descriptive pilot study evaluated the role and impact of two pediatric critical care nurse practitioners (PCCNPs) in the pediatric intensive care unit (PICU) at a tertiary care children's hospital. Questions posed included: 1) Are parents satisfied with the care their child and family received from the PCCNP in the PICU?; 2) Are staff nurses satisfied with the role of the PCCNP in the PICU?; and 3) Is there a difference between the care delivered by the PCCNP and the pediatric resident staff in nutritional management and discharge planning? Study methodology included a retrospective chart review of 25 PCCNP and 25 pediatric resident staff patient charts and a questionnaire survey of a convenience sample of parents and staff nurses over a 6-month study period. Overall, parents reported that the care their children received from the PCCNP was adequate. Staff nurses were satisfied with nurse practitioner (NP) care and supported the PCCNP role. There were no significant differences in the nutritional management of the children cared for by residents and PCCNPs. However, the PCCNPs initiated documentation of discharge planning with a greater frequency and earlier in the child's hospitalization, as compared to medical staff practice. Study findings support the use of the PCCNP in the PICU as care is comparable to that of the pediatric resident staff.
Beginning in 1976 the Department of Health Education and Welfare of the United States Government (DHEW) and the Pan American Health Organization, which is the regional office of the World Health Organization (PAHO-WHO), jointly developed a study of health planning as currently practiced around the world. This thrust to extend our understanding and capability of application of health planning was recognized at PAHO-WHO and DHEW as being long overdue, given the diversity of health planning efforts, the thinness of theory and the frequently unsatisfactory results of health sector planning in so many countries. In 1976 a series of descriptive-analytical studies were commissioned from 17 countries representing nearly every continent and every stage of development. These studies were further analyzed and abstracted and became the basis for a 5-day discussion in Copenhagen in 1977 among 35 practicing and academic health planners gathered from 16 countries, WHO, and DHEW. The thrust of the first assembly was to identify the determinants of (1) the establishment of formal health planning machinery, (2) the scope and content of concerns assigned to health planning, (3) the participants in the process, and (4) the relationships of planners to policy makers and implementors. In 1978 the second 5-day meeting was held in New Orleans to analyze the methodologies of health planning and to determine what could be generalized and disseminated as guidance to all countries. This was based on a new series of methodologically focused case studies which were abstracted and made available to each of the 53 health planning participants from 22 countries, PAHO-WHO, and DHEW. The four major foci of this conference were (1) the state of the art in health planning methodology, (2) how methods are being developed and adapted, (3) identification of major methodological shortcomings or constraints, and (4) surmounting the difficulties facing health planning in affecting major health-influencing forces which lie outside the territory traditionally considered to be part of the health sector. This article is a report on some of the things the author learned from participating in what he considers the two most informative planning meetings he ever attended.
This paper is a case study of the linkages between selected characteristics of the social organization in a particular ethnic group and reproductive values and behavior. Specifically, it examines factors that might be responsible for the acceptance of contraception and an expressed desire for a relatively small number of children among the Pare of Northern Tanzania. It is hypothesized that with the increasing shift towards wage labor and diminishing dependence on land and lineage relations, there is a growing reliance on the conjugal bond and the development of a partnership marriage in which husbands and wives perceive their interests as mutual. This facilitates communication, particularly about family planning. Research methodology consisted of a two-pronged approach and combined an intensive ethnographic study of the households in the Ugwengo District of the Pare mountains with individual surveys administered to a sample of 512 women and in-depth interviews conducted with 20 women regarding the value of children and contraceptive and birth histories.
PURPOSE: The combination of permanent low-dose-rate interstitial implantation (LDR-BRT) and external beam radiotherapy (EBRT) has been used in the treatment of clinically localized prostate cancer. While a high radiation dose is delivered to the prostate in this setting, the actual biologic dose equivalence compared to monotherapy is not commonly invoked. We describe methodology for obtaining the fused dosimetry of this combined treatment and assigning a dose equivalence which in turn can be used to develop desired normal tissue and target constraints for biologic-based treatment planning. METHODS AND MATERIALS: Patients treated with this regimen initially receive an I-125 implant prescribed to 110 Gy followed, 2 months later, by 50.4 Gy in 28 fractions using intensity-modulated external beam radiotherapy. Ab initio methodology is described, using clinically derived biologic parameters (alpha, beta, potential doubling time for prostate cancer cells [T(pot)], cell loss factor), for calculating tumor control probability isoeffective doses for the combined LDR and conventional fraction EBRT treatment regimen. As no such formalism exists for assessing rectal or urethral toxicity, we make use of semi-empirical expressions proposed for describing urethral and rectal complication probabilities for specific treatment situations (LDR and fractionation, respectively) and utilize the notion of isoeffective dose to extend these results to combined LDR-EBRT regimens. RESULTS: The application to treatment planning of the methodology described in this study is illustrated with real-patient data. We evaluate the effect of changing LDR and EBRT prescription doses (in a manner that remains isoeffective with 81 Gy EBRT alone or with 144 Gy LDR monotherapy) on rectal and urethral complication probabilities, and suggest that it should be possible to improve the therapeutic ratio by exploiting joint LDR-EBRT planning. CONCLUSIONS: We describe new methodology for biologically based treatment planning for patients who receive combined low-dose-rate brachytherapy and external beam radiotherapy for prostate cancer. Using relevant mathematical tools, we demonstrate the feasibility of fusing dose distributions from each treatment for this combined regimen, which can then be expressed as isoeffective dose distributions. Based on this information, dose constraints for the rectum and urethra are described which could be used for planning such combination regimens.
"Planning is under way for the U.S.A. bicentennial census in 1990. The U.S. Census Bureau sponsored a study panel under the U.S. Committee on National Statistics to consider key aspects of methodology for the census and to recommend priority areas for research and testing. The recommendations of the Panel on Decennial Census Methodology, which are summarized in this paper, cover four main topics: adjustment of the census counts for coverage errors, methods of coverage evaluation, uses of sampling in obtaining the count, and uses of administrative records in improving the quality of selected content items."
The purpose of this year-long study, conducted in a medical ward at Edmundston Regional Hospital of New Brunswick, was to lay the groundwork for data collection as the first step of the nursing process. By adhering to the Collerette and Delisle planned change methodology, the author was able to overcome many of the usual barriers, such as lack of training and staff shortages, and build solid support for her pilot project. The results surpassed all expectations and the change process has instilled a new sense of pride among nurses at the hospital and sparked the development of training sessions for other nurses in the region.
The delivery of primary health care (PHC) services is now recognized as a crucial element in the development of low-income regions. Effective delivery of these services requires the ability to solve a variety of policy decision problems. Research has demonstrated the utility of operations research/management science (OR/MS) models and methodologies in the analysis and solution of such problems. However, this approach may be limited in some regions by the data and computational requirements of the models. Intuitive approaches in the spirit of OR/MS models, termed heuristics, can provide an effective alternative in such cases. The current paper proposes a general heuristic procedure for solving problems of PHC delivery in developing regions. The heuristic is applied, in detail, to the problem of identifying "best" community financing schemes for PHC services in low-income sections of Rio de Janeiro, Brazil.
BACKGROUND: The American Joint Committee on Cancer (AJCC) published the 1st edition of the Cancer Staging Manual in 1977 and began using T (tumor extent), N (regional lymph node status), and M (the presence or absence of distant metastasis) in an organized staging scheme to express the extent of disease in a number of cancer sites. The goal of this program has been to provide physicians and others with a useful methodology to plan treatment, project prognosis, and measure outcome end results. Until recent years, this system has incorporated only elements of anatomic extent of the tumors determined by clinical and pathologic methods. At the present time an increasing number of nonanatomic cancer prognostic factors are being identified and studied. Some of these factors currently are being used for outcome predictions and treatment decisions. METHODS: To begin the process of identifying and validating these prognostic factors to refine the present TNM system, the AJCC convened a Prognostic Factors Consensus Conference to evaluate the roles of biologic, genetic, molecular, and other nonanatomic factors in staging cancer. Working groups were appointed for carcinomas of the breast, colorectum, prostate, and ovary and experts in each of these areas were invited to participate. Emphasis was placed on evaluating existing data and the correlation of these data with survival. RESULTS: None of the groups believed that there were sufficient data at the present time to merit incorporation of serum markers into the TNM system for the four tumors under consideration, although this soon might become possible in prostate carcinoma after the evaluation of survival data from multiple institutions. Recommendations were made regarding the emerging sentinel lymph node technique, the need for an increased use of histopathology in the staging of breast and ovarian carcinomas, and the use of additional histologic staining techniques for the detection of "micrometastases" in lymph nodes. A number of additional recommendations were made for changes to the TNM system that did not involve serum markers and other nonanatomic cancer prognostic factors. CONCLUSIONS: These recommendations are presented for the purpose of discussion and evaluation and do not yet represent formal proposals for a change in the AJCC TNM system of staging.
In order to avoid undesirable side effects such as high contents of mycotoxins in food and feed, measurements at critical steps of the food and feed production chain are performed. These measurements need to be accurate and precise to satisfy these aims. The accuracy and precision requirements to measurements form the basis of the Bureau Communautaire de Référence (BCR)-and Measurements and Testing (M&T)-Projects. Such projects aim to improve and/or develop analytical methodology, sampling plans, to harmonise agreement of results between European Union Member States and to prepare suitable certified reference materials (CRMs). The selection of the matrix CRMs and their corresponding level of mycotoxin contamination is made on the basis of requirements of the applied analytical procedures, stability requirements, regulations, norms, and inter-or intra-trade agreements which are in relation to quality specifications of imported and/or exported goods. The availability of appropriate matrix CRMs is not only a prerequisite for the implementation of directives and norms. It allows the validation of new methods and provides a possible solution to trade disputes, means for the statistical control of analytical results, tools for laboratory accreditation, and it is the basis for harmonisation and traceability of proficiency schemes.
"This paper will investigate the characteristics of population allocation between two regions in the presence of migration cost. It will also examine both populations and the non-migration range of the initial population in which migration does not occur, in social optimum and market equilibrium with central government intervention, to reveal migration cost externality, and to propose a remedy for it." The author finds that "migration cost gives the social planner an additional burden of population reallocation, and it has an important effect upon an individual's decisions on migration in a decentralized market mechanism."
This study evaluates a unique and completely different approach from the original removal technique. The main objective of this technique is to facilitate removal of widely-spaced, deeply-positioned, and misplaced Norplant capsules. A local anesthetic is injected deep and perpendicular to the long axis of the Norplant rods. The hypodermic needle is left in place underneath the six silicone rods for the entire removal procedure. One or two 3-4mm vertical incisions were made between the capsules over the needle. The Norplant rods were dissected free from the fibrous tissue and the skin with a #11 blade. A curved mosquito forceps was inserted between the skin and the Norplant rod, to hook and deliver the capsule through the incision, from where it can be easily removed. This method resulted in far less time, effort, and skill from the health care provider, no damage to the capsules, and much less trauma to the clients.
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