Where to from here?

Although this conceptual framework is easy to understand, the data requirements for the mathematical model that underpins the framework are complex and must be defined carefully. In our framework, simulations of the health system are used to provide needs-based estimates that are aimed at optimizing outcomes. This type of model builds on research conducted at the macro, meso, and micro levels in order to reflect the complexity of relationships in the health human resource process. The papers in this issue of the Journal provide insight into specific constructs of the model. At the macro level, Tomblin Murphy explores methodological challenges in HHRP research. She examines common assumptions and the validity of their use in modelling in all aspects of the proposed framework. Tourangeau and colleagues report on the impact of hospital nurse-staffing decisions on 30-day mortality rates. Their model adds to our knowledge of the relationships among the management, deployment, and utilization of nursing services and patient/population outcomes. Shamian and colleagues explore the relationship between hospital-level indicators of the work environment and aggregated indicators of health and well-being for registered nurses employed in acute-care hospitals in the province of Ontario. This paper contributes to our understanding of how management decisions regarding the work environment influence nurse outcomes. Manojlovich and Ketafian explore the conflict between the practice of nursing and the organizational structure of many hospitals. This study provides insight into the management aspects of how the work unit is organized and the process of care delivery. Zboril-Benson examines the reasons for nurse absenteeism in the province of Saskatchewan. Birch describes the need for the planning process to take into account demographic changes in both populations and provider groups. A major challenge in modelling health human resources is access to meaningful databases for planning purposes. Pringle describes a unique Ontario initiative currently underway to develop and validate a nurse-sensitive set of data that will be routinely collected and will enhance HHRP in that province. Since the science that underpins HHRP is complex and rapidly changing, few books have been written on the subject. Reflecting the dynamic nature of the science, Tomblin Murphy and Barrath provide an excellent review of "grey literature" and useful Web sites for those interested in HHRP.     

Can dogs prime autistic children for therapy? Evidence from a single case study

BACKGROUND AND OBJECTIVES: Canine-assisted therapy has been receiving growing attention as a means of aiding children with autism spectrum disorder (ASD). Yet, only limited studies have been done and a great deal of literature related to this intervention is anecdotal. The present study aims at providing additional quantitative evidence on the potential of dogs to positively modulate the behavior of children with ASD. SETTINGS/LOCATION, SUBJECTS, AND INTERVENTIONS: A 12-year-old boy diagnosed with ASD was exposed, at his usual treatment location (the Portuguese Association for Developmental Disorders and Autism at Vila Nova de Gaia, Portugal), to the following treatment conditions: (1) one-to-one structured activities with a therapist assisted by a certified therapy dog, and (2) one-to-one structured activities with the same therapist alone (as a control). To accurately assess differences in the behavior of the participant between these treatment conditions, the therapist followed a strict research protocol. The behavior of the participant was continuously video-recorded during both treatment conditions for further analysis and comparison. Treatment outcomes: In the presence of the dog, the participant exhibited more frequent and longer durations of positive behaviors (such as smiling and positive physical contacting) as well as less frequent and shorter durations of negative behaviors (such as aggressive manifestations). CONCLUSIONS: These findings are in accordance with previous experimental work and provide additional support for the assertion that dogs can prime autistic children for therapy. Ultimately, this study may contribute toward a change for full acceptance of canine-assisted therapy programs within the medical milieu. Additional studies using a similar research protocol on more autistic children will certainly help professionals to work on the most effective methods to individually serve this population through canine-assisted interventions.     

Cell therapies for neurological disease – from bench to clinic to bench

The lack of any meaningful regeneration in the adult central nervous system (CNS) subsequent to damage or degeneration stimulated the concept of replacement of the deficient cells by transplantation. Thus, much time and effort has been spent on investigating the potential of cell replacement therapy for repair in a range of conditions of the CNS over the last 25years. As promising proof of principle basic science results were slowly converted to success in clinical transplantation trials in Parkinson’s disease (PD), the future seemed very encouraging for cell therapy. However, the recent randomised, double-blind, placebo-controlled studies of fetal neural transplantation in PD have produced more equivocal results, which has dampened enthusiasm for this approach. However, whilst the translation of cell therapies to the clinic is in limbo, the emergence of stem cells as a source of the replacement tissue has revitalised the laboratory-based studies. This paper attempts to reconcile these disparate views and put forward the authors’ view on the future of this form of biological therapy and its implications for related therapies.     

DNA vaccines and apoptosis: to kill or not to kill?

The apoptotic machinery has become the latest target of vaccinologists attempting to improve the efficacy of DNA vaccines. While workers have previously sought to induce apoptotic death in transfected DCs as a means to activate immunity, a new approach (see related article on pages 109–117) instead seeks to delay apoptosis in host DCs after DNA vaccination.     

Renal-dose dopamine: from hypothesis to paradigm to dogma to myth and, finally, superstition?

Acute renal failure (ARF) is common in the critically ill and is associated with a high mortality rate. Its pathogenesis is not understood. Because animal models use ischemia to induce experimental ARF, there is the widespread belief that lack of blood flow is responsible for ARF. Low-dose dopamine (LDD) has been shown to increase renal blood flow in animal and in human volunteers. Thus, it has been administered to humans for almost 3 decades in the belief that it would lead to renal arterial vasodilation and increase renal blood flow (RBF). However, the etiology of ARF in critical illness is likely multifactorial, and the contribution of hypovolemia and reduced renal perfusion is unknown. Furthermore, interindividual variation in the pharmacokinetics of dopamine typically results in poor correlation between blood levels and administered dose, making accurate and reliable delivery of LDD difficult. Finally, dopamine is a proximal tubular diuretic that increases Na(+) delivery to tubular cells, thus increasing their oxygen demands. Accordingly, even if LDD were able to preferentially increase RBF, there is no guarantee that it would restore renal parenchymal oxygen homeostasis. More important, 2 meta-analyses and a large double-blind, prospective, multiple-center, randomized controlled trial have failed to demonstrate that dopamine protects the kidney in critically ill patients with ARF. Currently, there is insufficient evidence to support the use of renal-dose dopamine in the intensive care unit.     

Corticosteroids in sepsis: from bench to bedside?

The use of corticosteroids in patients with septic shock has been recently revisited and the use of low dose corticosteroids led to very promising results, particularly in patients with corticosteroid insufficiency. We review the different mechanisms that can account for their beneficial effects in patients. Glucocorticoids display a wide spectrum of anti-inflammatory properties that have been identified in in vitro and in vivo experimental models (e.g., inhibition of production of pro-inflammatory cytokines, free radicals, prostaglandins and inhibition of chemotaxis, and adhesion molecule expressions.) In addition, glucocorticoids have profound effects on the cardiovascular system (e.g., increasing mean blood pressure, increasing pressor sensitivity, and therefore decreasing the duration of use of catecholamines during septic shock.) Through these anti-inflammatory and cardiovascular effects, low doses of glucorticoids may improve septic shock survival.     

Canadians�� willingness to receive care from physician assistants

Objective

To determine the willingness of Canadians to accept treatment from physician assistants (PAs).

Design

Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients’ preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.

Setting

Vancouver, BC.

Participants

Two hundred twenty-nine mothers attending a hospital with their children.

Main outcome measures

The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.

Results

Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).

Conclusion

These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.     

Growth factor release from biodegradable hydrogels to induce neovascularization

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Silver Nanoparticles from Cow’s Milk to Combat Multidrug-Resistant Gram-Negative Bacteria from Clinical Isolates

Proceedings of the National Academy of Sciences, India Section B: Biological Sciences - The emergence of multidrug-resistant (MDR) bacteria is causing severe and lethal human infections and is...     

Hip fracture treatments--what happens to patients from residential care?

Hip fractures are a growing problem and new models of care have been called for. However, patients from residential care are rarely considered in these discussions. Hip fracture is a common serious problem for older people in residential care with profound effects on subsequent mobility and quality-of-life. There are no Australian data documenting differences in hospital treatments offered to patients from the community and residential care to inform discussions. In a prospective audit we describe the treatment and 4 month outcomes of patients with fractured hips who were admitted to Flinders Medical Centre in South Australia from the community and residential care between August 1998 and June 1999. Information was collected on prefracture health, types of surgical and rehabilitation treatments and dependency. Of the 215 older adults who were admitted during this time, 183 agreed to participate (119 from community and 64 from residential care). Surgical management of the fracture was not affected by admission accommodation. Those from residential care had short hospital stays, less rehabilitation and access to physiotherapy. Although 61% of those from residential care were classified as independently mobile prefracture, by 4 months this had declined to 32% of survivors. Strategies to improve outcomes in those from residential care include: early identification of those walking independently prefracture with assessment by rehabilitation teams. Inclusion of liaison with community therapists in the clinical pathway and in selected cases use of 'rehabilitation at home' services to provide physiotherapy services should be considered.