New scientific opportunities and old obstacles in vaccine development.

The present status of and priorities for vaccine development are described, and the historical conditions under which vaccines have been developed are contrasted with newer technologies for such development. Current programs, the opportunities they present, and the obstacles to their implementation are summarized.     

Getting the message across: opportunities and obstacles in effective communication in hypertension care

Effective communication is a prerequisite for any successful encounter between patient and provider. Nevertheless, it is unclear how/where communication can impact/affect adherence to antihypertensive medication, and maintenance of lifestyle changes to control blood pressure targets. Poor physician communication is correlated with a higher risk of treatment nonadherence. Given the high rates of hypertension globally, this review serves to enlighten aspects of the communication exchange from a provider, context, and patient perspective. Relevant articles were analyzed to assess barriers, solutions, and optimizations for communication with hypertensive patients. To support the findings, a model of communication in the context of hypertension treatment is presented, which comprises three phases: comprehension and acceptance, translation into action, and long-term retention. Secondly, an analysis of care providers (bedside manner, verbal/nonverbal communication, empathy and sex, time, knowledge base), context (format and tailoring of the message, and physical environment), and patient-related factors (sex, socio-economic status, language and health literacy, culture, age, psychological factors) were assessed in relation to hypertension. Current literature is limited regarding reciprocal communication, adaptive packaging of messages, and active verification of effective communication. To improve communication, hypertension care programs could benefit from better communication training, more team-based approaches, and flexible tools based on information technology.     

Screening for HIV-related neurocognitive impairment in clinical practice: Challenges and opportunities

With increasingly successful management of HIV, focus has shifted away from AIDS-related complications to other chronic co-morbidities. For HIV-related cognitive problems, the true aetiopathogenesis and epidemiology remains unclear. Rather than a systematic review, this paper presents the challenges and the opportunities we faced in establishing our own clinical service. Papers were identified using Pubmed and the terms “screening”, “HIV” and “neurocognitive”. This article covers the background of HIV-associated neurocognitive disorders (HAND) with a focus on HIV-related neurocognitive impairment (NCI), detailing classification, prevalence, diagnostic categories and diagnostic uncertainties. Screening is discussed, including a comparison of the available screening tools for cognitive deficits in HIV-infected patients and the importance of practice effects. Discussed also are the normal ranges and the lack thereof and potential investigations for those found to have impairments. We conclude by discussing the role of NCI screening in routine clinical care at the current time.     

Prevention of alcohol problems in the 21st century: challenges and opportunities

The community is the "new frontier" for alcohol and other drug prevention. New prevention initiatives at the community level suggest that effective strategies will often be quite different from national or state policies and will require a different perspective. Alcohol and other drug use is part of routine community life and must be considered in the context of the community, which is itself a dynamic and self-adapting system. To develop effective community-level interventions, prevention planners and policy makers must understand how various aspects of the community influence alcohol and other drug use and even contribute to alcohol and other drug problems. This paper outlines the basis for a systems approach to community prevention and the policy options that this approach suggests. It also examines the new science of complexity, differentiates between catchment and a systems approach to prevention, describes a public health model within a systems approach, and describes using local policy as a means to produce system changes as well as recent findings from community-based prevention efforts that employed local alcohol policies.     

Aortic valve replacement: current clinical practice and opportunities for quality improvement

This is a review of the current clinical practice and opportunities for quality improvement in aortic valve replacement surgery. The topics include trends and regional variation in procedure rates, and changes in the use of aortic valve replacement among the elderly. Recent developments guiding the choice of prosthetic valves and trends in in-hospital mortality rates for aortic valve surgery are summarized. Lastly, a discussion of topics relevant to clinical practice improvement including the implementation of clinical practice guidelines, the need for consensus on risk adjustment, better understanding of volume-outcome effects, and the opportunities for comprehensive assessment of aortic valve surgery.     

Continuation with cotrimoxazole prophylaxis for the prevention of opportunistic infections in HIV-infected persons in rural Zimbabwe: feasibility, obstacles and opportunities

We examined the outcomes of a World Health Organization (WHO) recommended programme offering cotrimoxazole (CTM) prophylaxis to 908 HIV-positive individuals in rural Zimbabwe, who accepted enrolment in the treatment programme. Outcomes included duration in programme, time between visits, relationship and marital status. Mean duration of participation in the programme was 224 days. The mean time between visits decreased from 11.2 weeks, between visit 1 and 2, to 4.3 weeks between visit 11 and 12. Statistical analysis showed significant positive correlations between duration in programme and participant age, participant relationship status and the partner's state of affairs. Statistical analysis showed no significant correlation between duration in programme and gender. Results indicate that if continuation is demonstrated for the first 4 to 6 months, participants will continue with the CTM programme. Results also reflect the constrained feasibility of CTM prophylaxis in rural Africa as well as the need to target subpopulations, such as young people, patients and their spouses for focused HIV/AIDS education initiatives.     

Prevention of hypertrophic cardiomyopathy-related deaths: theory and practice

In 1958, the British forensic pathologist, Donald Teare, reported a family in which eight young people had died suddenly from asymmetrical hypertrophy of the left ventricle. Five decades on, the prevention of premature death from ventricular tachyarrhythmia, heart failure and stroke remains a major aim of clinical management in what is now called hypertrophic cardiomyopathy. In this paper, we review the underlying mechanisms of death and discuss the strengths and weaknesses of current international guidelines for the identification and treatment of high-risk patients.     

Treatment of non-ST-elevation acute coronary syndrome in the elderly: current practice and future opportunities

The care of elderly patients with non-ST-elevation acute coronary syndrome is challenging, given the wide variability in physiologic condition and preferences among this patient group. Due to a higher burden of comorbidity, the elderly face high risks for death and complications from non-ST-elevation acute coronary syndrome relative to younger patients. Accordingly, they also have greater potential benefits from effective therapies. Antithrombotic therapy, invasive cardiac care, lipid lowering, and prevention advice, however, are all used less often in the elderly, even when no contraindications exist. Attention to individualized dosing and safety monitoring is also important for elderly patients. Increased awareness of the beneficial impact of therapies on outcomes in the elderly, along with vigilance for adverse events, should enable care to move from the state of uncertainty to opportunity in this high-risk population.     

The practice of rheumatology in Kenya: challenges and opportunities. ILAR visiting professorship program report

International League of Associations for Rheumatology (ILAR) is committed to promoting the care of those with musculoskeletal diseases. To further this aim, ILAR sponsors visiting professorships to countries with minimal or underdeveloped rheumatology services to promote the awareness and improve skills in the management of musculoskeletal conditions. Professor Luis Espinoza was sponsored and visited Kenya in March 2005.     

Patient suffering and caregiver compassion: new opportunities for research, practice, and policy

The purpose of this article is to stimulate discussion and research about patient suffering and caregiver compassion. It is our view that these constructs are central to understanding phenomena such as family caregiving, and that recognizing their unique role in the caregiving experience provides new directions for intervention research, clinical practices, and social policy. We first define and characterize these constructs, review empirical evidence supporting the distinct role of suffering and compassion in the context of caregiving, and then present a conceptual model linking patient suffering with caregiver compassion. We conclude with a discussion of implications and future directions for clinical intervention, research, and policy.     

Smoking prevention: obstacles and possibilities

A brief overview is given of the disastrous effects of tobacco smoking on health, the environment and the economy. Obstacles for prevention are exemplified by the strong addictive property of nicotine, the ruthlessness and greed of the tobacco industry, and the ambivalence still demonstrated by the political and the health professional community in the fight against tobacco. A successful comprehensive tobacco control strategy is recognized and promoted by the first global health convention, the World Health Organization (WHO) Framework Convention on Tobacco Control. WHO has great expectations of the health community to support the implementation of the convention: who else has a greater responsibility?     

Islet encapsulation: advances and obstacles

It has been known for decades that encapsulation can protect transplanted islets from immune destruction in rodents, but it has proved difficult to extend this success to large animals and humans. A new study in this issue by Jacobs-Tulleneers-Thevissen et al (doi: 10.1007/s00125-013-2906-0) advances the field by showing that human islets contained in alginate capsules can function very well, not only in the peritoneal cavity of mice, but also in a human with type 1 diabetes. Many obstacles must still be overcome, but this technology has the potential to safely protect transplanted beta cells from autoimmunity and allorejection.     

Prevention for positives: challenges and opportunities for integrating prevention into HIV case management.

Despite nearly 20 years of HIV prevention efforts, rates of new HIV infection persist at an alarming rate. As successful antiretroviral medications enable many HIV infected persons to live longer, healthier lives, interventions are necessary to support ongoing prevention and reduced risk behaviors. This article describes a survey that was used to assess the opportunities and challenges related to the integration of prevention screening into the work of HIV/AIDS case managers. The article describes the survey, reports the findings (N = 101), and concludes with a discussion of issues that must be addressed prior to incorporating prevention screening into HIV/AIDS case management.     

Prevention of postmenopausal osteoporosis with pharmacological therapy: practice and possibilities

Postmenopausal osteoporosis (PMO) is a common disease that will become more prevalent in the future, with costly implications for public health. Prevention of the disease and its consequences, namely fractures, is therefore, important for both the individual and society. This review discusses: the goals of PMO prevention; the identification of women at risk, including the use of bone mineral density and bone turnover markers; the relevance in the prevention setting of various current guidelines for PMO management; recent data on therapeutic options for the treatment and prevention of PMO, in particular bisphosphonates, hormone replacement therapy and several other new pharmacological agents. It concludes that it is crucial for PMO prevention to start before disease onset and that, in the light of recent evidence, the existing guidelines need updating if they are to continue to be relevant.