Hyak mortality monitoring system: innovative sampling and estimation methods - proof of concept by simulation

Traditionally health statistics are derived from civil and/or vital registration. Civil registration in low- to middle-income countries varies from partial coverage to essentially nothing at all. Consequently the state of the art for public health information in low- to middle-income countries is efforts to combine or triangulate data from different sources to produce a more complete picture across both time and space - data amalgamation. Data sources amenable to this approach include sample surveys, sample registration systems, health and demographic surveillance systems, administrative records, census records, health facility records and others. We propose a new statistical framework for gathering health and population data - Hyak - that leverages the benefits of sampling and longitudinal, prospective surveillance to create a cheap, accurate, sustainable monitoring platform. Hyak has three fundamental components: Data amalgamation: A sampling and surveillance component that organizes two or more data collection systems to work together: (1) data from HDSS with frequent, intense, linked, prospective follow-up and (2) data from sample surveys conducted in large areas surrounding the Health and Demographic Surveillance System (HDSS) sites using informed sampling so as to capture as many events as possible;Cause of death: Verbal autopsy to characterize the distribution of deaths by cause at the population level; andSocioeconomic status (SES): Measurement of SES in order to characterize poverty and wealth. We conduct a simulation study of the informed sampling component of Hyak based on the Agincourt HDSS site in South Africa. Compared with traditional cluster sampling, Hyak's informed sampling captures more deaths, and when combined with an estimation model that includes spatial smoothing, produces estimates of both mortality counts and mortality rates that have lower variance and small bias.

Elevated Intracranial Pressure Diagnosis with Emergency Department Bedside Ocular Ultrasound

Bedside sonographic measurement of optic nerve sheath diameter can aid in the diagnosis of elevated intracranial pressure in the emergency department. This case report describes a 21-year-old female presenting with 4 months of mild headache and 2 weeks of recurrent, transient binocular vision loss. Though limited by patient discomfort, fundoscopic examination suggested the presence of blurred optic disc margins. Bedside ocular ultrasound (BOUS) revealed wide optic nerve sheath diameters and bulging optic discs bilaterally. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 54 cm H2O supporting the suspected diagnosis of idiopathic intracranial hypertension. Accurate fundoscopy can be vital to the appropriate diagnosis and treatment of patients with suspected elevated intracranial pressure, but it is often technically difficult or poorly tolerated by the photophobic patient. BOUS is a quick and easily learned tool to supplement the emergency physician's fundoscopic examination and help identify patients with elevated intracranial pressure.

Biofilm formation by the fungal pathogen Candida albicans: development, architecture, and drug resistance

Biofilms are a protected niche for microorganisms, where they are safe from antibiotic treatment and can create a source of persistent infection. Using two clinically relevant Candida albicans biofilm models formed on bioprosthetic materials, we demonstrated that biofilm formation proceeds through three distinct developmental phases. These growth phases transform adherent blastospores to well-defined cellular communities encased in a polysaccharide matrix. Fluorescence and confocal scanning laser microscopy revealed that C. albicans biofilms have a highly heterogeneous architecture composed of cellular and noncellular elements. In both models, antifungal resistance of biofilm-grown cells increased in conjunction with biofilm formation. The expression of agglutinin-like (ALS) genes, which encode a family of proteins implicated in adhesion to host surfaces, was differentially regulated between planktonic and biofilm-grown cells. The ability of C. albicans to form biofilms contrasts sharply with that of Saccharomyces cerevisiae, which adhered to bioprosthetic surfaces but failed to form a mature biofilm. The studies described here form the basis for investigations into the molecular mechanisms of Candida biofilm biology and antifungal resistance and provide the means to design novel therapies for biofilm-based infections.

Biofilm formation by the fungal pathogen Candida albicans: development, architecture, and drug resistance

Biofilms are a protected niche for microorganisms, where they are safe from antibiotic treatment and can create a source of persistent infection. Using two clinically relevant Candida albicans biofilm models formed on bioprosthetic materials, we demonstrated that biofilm formation proceeds through three distinct developmental phases. These growth phases transform adherent blastospores to well-defined cellular communities encased in a polysaccharide matrix. Fluorescence and confocal scanning laser microscopy revealed that C. albicans biofilms have a highly heterogeneous architecture composed of cellular and noncellular elements. In both models, antifungal resistance of biofilm-grown cells increased in conjunction with biofilm formation. The expression of agglutinin-like (ALS) genes, which encode a family of proteins implicated in adhesion to host surfaces, was differentially regulated between planktonic and biofilm-grown cells. The ability of C. albicans to form biofilms contrasts sharply with that of Saccharomyces cerevisiae, which adhered to bioprosthetic surfaces but failed to form a mature biofilm. The studies described here form the basis for investigations into the molecular mechanisms of Candida biofilm biology and antifungal resistance and provide the means to design novel therapies for biofilm-based infections.

Goals and Strategies for Teaching Death and Dying in Medical Schools

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.

Infection characteristics of an Ecuadorian Trypanosoma cruzi strain with reduced virulence

A human isolate of Trypanosoma cruzi obtained from Guayaquil, Ecuador (Guayas strain) was examined for its infectivity of the resistant C57Bl/6 (B6) and the susceptible C3H (He) mouse strains and compared to infection with the known virulent Brazil strain. C3H mice were capable of surviving acute Guayas infection, whereas the Brazil infection was fatal for this mouse strain. Both C3H and B6 mice showed a greatly reduced (over 10-fold) parasitemia during Guayas infection compared to Brazil infection. Histologic examination of heart tissue from Guayas-infected B6 and C3H mice indicates little inflammation, unlike what is typically seen in B6 mice chronically infected with the Brazil strain. There appears to be no remarkable difference in the anti-parasite antibody responses (as measured by ELISA and western blot) in mice infected 100 days with Guayas or Brazil parasites. Western blot analysis of the anti-heart response indicates no response during Guayas infection to a 43-kDa heart tissue glycoprotein that is a target of antibodies from B6 mice infected with Brazil strain. The Guayas strain, therefore, provides an infection that generates a low parasitemia and strong anti-parasite responses in the absence of specific anti-heart autoimmunity and obvious myocarditis. In vitro infection characteristics of these 2 parasite strains were studied in cultures of macrophages, myocytes, and fibroblasts by microscopic examination of stained slide cultures. In both short-term (24 hr) and long-term (15 day) experiments, Brazil strain infection was shown to have a greater infection rate with a higher number of parasites per cell than Guayas infection for all host cell types.(ABSTRACT TRUNCATED AT 250 WORDS)

CEO summit. Building the new health care delivery alliance, Part III. Roundtable discussion

In cooperation with McManis Associates, Hospitals & Health Networks recently convened a CEO summit on physician/hospital integration activities. In the third report of a three-part series on the summit, leading health care executives discuss investor capital needs, strategic information management needs, and the management competencies required for capitated managed care success.

CEO Summit. Building the new health care delivery alliance, Part II. Roundtable discussion

In cooperation with McManis Associates, Hospitals & Health Networks recently convened a CEO summit on physician/hospital integration activities. The summit was designed and facilitated by the senior staff of McManis Associates. Part I, which appeared in the May 5 issue, focused on the lessons being learned by those providers on the front lines of integration. This report focuses on aligning incentives and achieving cost-effectiveness.

Determination of orally coadministered nadolol and its deuterated analogue in human serum and urine by gas chromatography with selected-ion monitoring mass spectrometry

A cartridge serum and urine extraction procedure of the beta-adrenergic antagonist, nadolol, employing a cross-linked styrene-divinyl benzene macroreticular resin is described. Samples were analyzed as the silylated derivative by gas chromatography-mass spectrometry (GC-MS) using selected-ion monitoring. When nadolol was orally coadministered with its deuterated analogue, relative bioavailability could be demonstrated with six or fewer subjects. Employing a base-deactivated GC phase, the limit of detection is 1 ng and 0.5 ng/mL of serum for nadolol and the deuterated analogue, respectively. For levels of less than 10 ng/mL, the respective coefficients of variation are 4 and 2%. For concentrations of greater than 10 ng/mL, the CV is 1% for nadolol and nadolol-d9.

Identification and determination of the S-methyl metabolite of captopril in human plasma by selected-ion monitoring gas chromatography-mass spectrometry

The S-methyl metabolite of captopril was identified and determined in human plasma by positive chemical ionization selected-ion monitoring gas chromatography-mass spectrometry. After oral administration of 100 mg of captopril to healthy subjects, the maximum plasma level was 60-114 ng/mL. These data for the S-methyl metabolite of captopril were correlated to total and unchanged captopril levels. Captopril--identification and determination of the S-methyl metabolite in human plasma, gas chromatography-selected-ion monitoring mass spectrometry Gas chromatography-selected-ion monitoring mass spectrometry--determination of the S-methyl metabolite of captopril in human plasma after oral administration.

Who is the patient? A family case study of a recurrent dilemma in family practice

This article presents a family case study of a recurrent dilemma in family medicine. The ethical dilemma involves what role the physician should play in mediating a conflict in a family when the health needs and wishes of the individual patient do not parallel those of the other family members. Who is the patient, the individual or the family? It is the authors' conviction that in meeting the needs of the presenting patient, the family context is of great importance. To this end, the authors delineate a framework for analyzing ethical conflicts of this nature, utilizing key ethical principles in combination with a systems perspective to aid in the clarification of such choices. The principles examined include autonomy, nonmaleficence, and justice. Also taken into account are the relevant facts, values, and the biases of the physician. Exploration of these factors allows the physician a comprehensive and logical approach for resolving such conflicts. Such a framework, however, can only provide guidance; it does not guarantee easy or uniformly acceptable alternatives to difficult issues.

Determination of captopril in human blood and urine by GLC-selected ion monitoring mass spectrometry after oral coadministration with its isotopomer

A modified electron-impact GLC-selected ion monitoring mass spectrometric method for captopril is described. Positive chemical ionization GLC-selected ion monitoring and direct chemical ionization confirms the specificity of this procedure for captopril and establishes the chemical ionization techniques as potential analytical methods. This procedure has been adapted to the simultaneous measurement of captopril and its isotopomer. The results of a pilot oral bioavailability study of four subjects receiving either 100 mg of captopril as a direct compression tablet or a solution concomitantly with a 100-mg solution of isotopomer is discussed.