Home About us Contact
|
Home About us Contact | ||
|
|
||
Important Obstacles (important + obstacle)
Selected AbstractsIn your opinion, what was the most important obstacle that had to be overcome in the development of emergency medicine as a specialty board?ACADEMIC EMERGENCY MEDICINE, Issue 2 20001976-198, 1982-1983 ABEM Director, John Wiegenstein MD President of ABEM No abstract is available for this article. [source] Paliperidone palmitate , review of the efficacy, safety and cost of a new second-generation depot antipsychotic medicationINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2010L. Citrome Summary Objective:, To describe the efficacy, safety and cost of paliperidone palmitate, a depot antipsychotic medication recently approved for the treatment of schizophrenia. Data sources:, A literature search was conducted by querying the websites http://www.pubmed.gov, http://www.fda.gov, http://www.accessdata.fda.gov/scripts/cder/drugsatfda and http://www.clinicaltrials.gov for the search term ,paliperidone palmitate'. Cost information was obtained from the pharmaceutical vendor servicing a local state-operated psychiatric facility. Study selection:, All available reports of studies were identified. Product labelling provided additional information. Data extraction:, Descriptions of the principal results and calculation of the number needed to treat (NNT) and number needed to harm (NNH) for relevant dichotomous outcomes were extracted from the study reports and synopses. Additional safety outcomes subject to NNH analysis were obtained from product labelling. Data synthesis:, Paliperidone palmitate is a newly available depot formulation of paliperidone (the 9-OH metabolite of risperidone). Upon injection into the deltoid or gluteal muscle, the release of the drug starts as early as day 1, reaches maximum plasma concentrations at 13 days and lasts for as long as 126 days. Maximum concentration following deltoid injection is approximately 28% higher compared with injection into the gluteal muscle, and thus paliperidone palmitate requires initiation by two initial deltoid injections spread 1 week apart to achieve therapeutic concentrations rapidly. Subsequent injections are at 4-week intervals. Acute efficacy was evidenced by four short-term double-blind, randomised, placebo-controlled, fixed-dose studies of acutely relapsed adult inpatients who met DSM-IV criteria for schizophrenia. NNT for a 30% or greater decrease in the Positive and Negative Syndrome Scale total score compared with placebo was consistently lower for the higher dose strengths of 156 and 234 mg, suggesting a therapeutic dose,response. Treatment with paliperidone palmitate at doses between 39 and 156 mg significantly delayed the time to recurrence of symptoms of schizophrenia after 24 weeks of maintained symptom stability. The NNT vs. placebo to avoid a recurrence of symptoms was 5 (95% CI 4,7). Overall, paliperidone palmitate was reasonably well tolerated, with low rates of extrapyramidal symptoms or body weight gain; however, these may be more common at higher doses. Injection site reactions occurred at a rate ranging from 4% to 10%, depending on the dose regimen, compared with 2% for the pooled placebo arms. The acquisition cost of a maintenance dose of paliperidone palmitate calculated on a per day basis is similar to that for risperidone microspheres, but about double the cost for oral paliperidone and approximately 19 times the cost of oral generic risperidone. Conclusions:, Paliperidone palmitate is efficacious for the acute and maintenance treatment of schizophrenia and is reasonably well tolerated. It offers several advantages over other available second-generation depot antipsychotics: it comes in prefilled syringes in a number of different dosage strengths; it does not require refrigeration; it does not require supplementation with oral antipsychotics; it can be administered once monthly; it can be administered with a very small bore needle; the injection volume is small; the injection site can be either the deltoid or gluteal muscles; it does not require an additional precautionary observation period after the injection. For patients for whom oral risperidone or paliperidone is otherwise effective, paliperidone palmitate offers a guaranteed delivery system that enhances adherence. However, the high acquisition cost of paliperidone palmitate will likely be an important obstacle to its routine use. [source] Despite the Northern Territories: Hokkaido's Courting of the Russian Far EastPACIFIC FOCUS, Issue 1 2003Tsuneo Akaha Recent studies of Japan's postwar policy toward Russia have persuasively argued that the intrinsic (symbolic and psychological) value rather than the instrumental (economic or strategic) value that the Northern Territories (Southern Kuriles) represents to Japan is the most important obstacle to the normalization of relations between the two countries. Theoretically, there are three ways in which the intrinsic value of the disputed islands might be substantially depreciated and the instrumental value of closer bilateral ties appreciated: (1) major concessions from Russia, which are highly unlikely, (2) the emergence of a security or strategic of common concern to Tokyo and Moscow prompting the two sides to offer mutual concessions on the territorial issue or indefinitely postpone its resolution, and (3) a substantial expansion of economic, cultural, and social ties between the Japanese and the Russians, dramatically improving Japanese attitudes toward Russia. This study explores the third possibility, with a particular focus on developments at the subnational level, the level that has been largely ignored by students of Russian-Japanese relations. Namely, the study examines relations between Hokkaido and the Russian Far East since the 1960s and asks: Do the same logic and dynamic that operate at the national level apply at the regional level? Does the intrinsic importance of the territorial dispute prevail over considerations of economic and other tangible values at the subnational level as it does at the national level? The paper concludes that while Hokkaido has not deviated from the Japanese government,s official position on the territorial issue,that all the islands belong to Japan, the dispute has not prevented the provincial administration, municipal governments, or nongovernmental organizations in Hokkaido from launching and sustaining initiatives to cement closer ties with their northern neighbors, with growing economic and human ties playing important roles in the process. [source] The quality of questions and use of resources in self-directed learning: Personal learning projects in the maintenance of certificationTHE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, Issue 2 2009T. Horsley PhD Abstract Introduction: To engage effectively and efficiently in self-directed learning and knowledge-seeking practices, it is important that physicians construct well-formulated questions; yet, little is known about the quality of good questions and their relationship to self-directed learning or to change in practice behavior. Methods: Personal learning projects (PLPs) submitted to the Canadian Maintenance of Certification program were examined to include underlying characteristics, quality of therapeutic questions (population, intervention, comparator, outcome [PICO] mnemonic), and relationships between stage of change and level of evidence used to resolve questions. Results: We assessed 1989 submissions (from 559 Fellows of the Royal College of Physicians and Surgeons of Canada [RCPSC]). The majority of submissions were by males (69.2%) aged 40,59 (59.4%) with an average of 24.3 (range 6,58, SD 11.1) years since graduation. The most frequent submissions were treatment (36.6%) and diagnosis (22.3%) questions. Half of all questions described ,2 components (PICO), and only 3.7% of questions included all 4 components. Cross tabulations indicated only 1 significant trend for the use of narrative reviews and the outcome "integrating new knowledge' (P < .000). Discussion: Self-directed learning skills comprise an important strategy for specialists maintaining or expanding their expertise in patient care, but an important obstacle to answering patient care questions is the ability to formulate good ones. Engagement in most major learning activities is stimulated by management of a single patient: formal accredited group learning events are of limited value in starting episodes of self-directed learning. Low levels of evidence used to address learning projects. Future research should determine how best to improve the quality of questions submitted and whether or not these changes result in increased efficiencies, more appropriate uses of evidence, and increased changes in practice behaviors. [source] Insulin therapy in EuropeDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S3 2002Werner A. Scherbaum Abstract The prevalence of type 1 diabetes is rising in all European countries, particularly in Scandinavia and the UK. Insulin therapy in Europe is strongly influenced by the results of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), both of which showed the importance of tight metabolic control in patients with diabetes. The importance of tight glycemic control is also emphasized in the Saint Vincent Declaration, which established 5-year goals for antidiabetic therapy in Europe. Insulin therapy in Europe has been significantly improved over the past 10,years, owing to a number of developments. These include increased use of intensive insulin therapy in patients with type 1 diabetes; the development of new insulin analogs, including insulin glargine for injection therapy and short-acting agents that are particularly suitable for use in pumpsand the establishment of comprehensive and standardized treatment goals and guidelines. Nevertheless, important obstacles must still be overcome to optimize therapy for patients with diabetes and reduce the long-term complications of this disease. These obstacles include low public awareness of diabetes and its symptoms, training of physicians as well as patients that is often insufficient to ensure adherence to professional guidelines for diabetes care, and limitations in communication among professional care providers. Copyright © 2002 John Wiley & Sons, Ltd. [source] Empirical evidence of underutilization of referrals for epilepsy surgery evaluationEUROPEAN JOURNAL OF NEUROLOGY, Issue 4 2010P. De Flon Background:, Epilepsy surgery is a treatment that can cure patients with intractable epilepsy. This study investigates whether referrals for epilepsy surgery evaluation are underutilized. Methods:, Patients with epilepsy aged 18,60 years were identified in a computerized registry held by public health care providers in a Swedish county using ICD codes. Clinical data and data on referral status for epilepsy surgery were obtained from the patients' medical records. Potential candidates for epilepsy surgery evaluation were identified using pre-specified criteria. Obstacles for referral were analysed by comparing clinical data in patients who were considered for referral and those who were not. Appropriateness of non-referral was evaluated against recommendations from the Swedish Council on Technology in Health Care (SBU). Results:, Of 378 patients with epilepsy in the registry, 251 agreed to participate. Of 251, 40 were already referred patients and 48 patients were identified as potential candidates for epilepsy surgery evaluation by study criteria. Referral had been considered but not performed in 15 of the potential candidates. Potential candidates not considered for referral were less likely to have seen a neurologist, to have had an EEG, CT and MRI, and more likely to have cognitive disturbances. Following the recommendations by the SBU, 28 of 48 potential candidates were identified as inappropriately not referred patients. Conclusion:, The number of missed referrals for epilepsy surgery evaluation was estimated to be 60 per 100 000 inhabitants. Several important obstacles were found for not referring patients for epilepsy surgery evaluation. [source] Social services and Primary Care Groups: a window of collaborative opportunity?HEALTH & SOCIAL CARE IN THE COMMUNITY, Issue 4 2000Bob Hudson This paper reports on the findings of two investigations into the relationship between social services and Primary Care Groups (PCGs): a national postal questionnaire and a series of regional seminars. The key findings of both explorations are summarised and placed in the context of other available evidence on the development of PCGs. Issues covered include: the background and status of social services representatives; preparation and support for the board role; feedback and accountability, and early contributions. It is concluded that progress is being made in bringing together the agendas and activities of PCGs and social services, and to a lesser extent the wider local authority, but that important obstacles remain in place. The enduring significance of the resource dependency model needs to be a key factor in emerging partnerships. [source] Secularism as a Barrier to Integration?INTERNATIONAL MIGRATION, Issue 3 2004The French Dilemma ABSTRACT This article focuses on the secularism debate currently taking place in France by examining how this issue impacts the integration of immigrants, particularly Muslim immigrants. Secularism is one of the key values of French Republicanism, but one which has been challenged by the establishment of a settled population of Muslim immigrants in France. The issue has been particularly highlighted by the affaire des foulards (headscarf affair), an ongoing debate over the rights of Muslim girls to wear a headscarf to secular French schools. Discussions of the principle of secularism and of its application have been even more intense in recent months with the publication in December 2003 of a report by the Stasi Commission, a commission set up by President Chirac to investigate the application of the principle of secularism, and by the passage of legislation intended to outlaw the wearing of any "overt" religious insignia in French schools. This article examines these recent developments in the context of the long-running debate over Muslim women's right to wear a headscarf in French schools. It argues that the current focus on secularism provides evidence of the return of assimilation as a primary objective of public policy (Brubaker, 2001) and the decreasing strength of the movement in favour of the droit à la différence (right to difference). Finally, the paper argues that this has provided important obstacles to the integration of certain groups of immigrants, particularly Muslim immigrants. [source] Outcomes-based trial of an inpatient nurse practitioner service for general medical patientsJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 1 2001Mathilde H. Pioro MD Abstract Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n = 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P > 0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P > 0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions. [source] Candidate's Thesis: Universal Newborn Hearing Screening in an Inner-City, Managed Care Environment ,THE LARYNGOSCOPE, Issue 6 2000Glenn Isaacson MD Abstract Objectives/Hypothesis Universal neonatal hearing screening (UNHS) programs aim to identify and treat educationally significant hearing loss in the first months of life. Several states have mandated UNHS for all newborns. Such programs have been successful in small, homogeneous populations. As larger states attempt to implement such programs, important obstacles have arisen, particularly in sparsely populated rural environments and in the inner city, where poverty, unstable living situations, and inadequate access to health care make follow-up of infants failing initial testing difficult. Study Design We performed a prospective longitudinal study e-amining the effects of increasingly comple- and e-pensive interventions designed to ensure that children failing initial hearing screening returned for complete evaluation and habilitation. Methods A UNHS program based on transient evoked otoacoustic emissions testing was implemented at Temple University Hospital, with 2,000 births per year. At 6 months into the program, efficacy was assessed and modifications in follow-up methodology were made in an attempt to improved rate of return of infants failing newborn screening. The effect of these interventions was reassessed 6 months later. Results In its first 12 months, the Temple University Infant and Young Child Hearing Intervention Initiative successfully screened 95% (2,031) of all newborns using transient evoked otoacoustic emissions. Collecting a complete database profile for each newborn, establishing rapport with the family, and offering immediate follow-up appointments yielded a 61% return rate after discharge. The addition of a dedicated project secretary, free day-care for siblings, and cab vouchers for transportation and the elimination of a requirement for health maintenance organization referrals increased follow-up yield to 75%. Conclusion Given adequate resources and planning, UNHS can be successful, even in economically depressed environments. [source] | |||||||||||||