Search

The article discusses the development of the sequential partial task practice (SPTP) strategy that can be used to improve student confidence when performing spinal thrust joint manipulation (TJM). Topics covered include details relating to the orthopaedic manual physical therapy (OMPT), the benefits of using the SPTP strategy, and methods used to evaluate the effects of the SPTP strategy. It also discusses the results obtained when the SPTP teaching strategy was used in an OMTP elective course.

Context: Information is limited regarding the readiness of primary care practices to make the transformational changes necessary to implement the patient-centered medical home (PCMH) model. Using comparative, qualitative data, we provide practical guidelines for assessing and increasing readiness for PCMH implementation. Methods: We used a comparative case study design to assess primary care practices' readiness for PCMH implementation in sixteen practices from twelve different physician organizations in Michigan. Two major components of organizational readiness, motivation and capability, were assessed. We interviewed eight practice teams with higher PCMH scores and eight with lower PCMH scores, along with the leaders of the physician organizations of these practices, yielding sixty-six semistructured interviews. Findings: The respondents from the higher and lower PCMH scoring practices reported different motivations and capabilities for pursuing PCMH. Their motivations pertained to the perceived value of PCMH, financial incentives, understanding of specific PCMH requirements, and overall commitment to change. Capabilities that were discussed included the time demands of implementation, the difficulty of changing patients' behavior, and the challenges of adopting health information technology. Enhancing the implementation of PCMH within practices included taking an incremental approach, using data, building a team and defining roles of its members, and meeting regularly to discuss the implementation. The respondents valued external organizational support, regardless of its source. Conclusions: The respondents from the higher and lower PCMH scoring practices commented on similar aspects of readiness-motivation and capability-but offered very different views of them. Our findings suggest the importance of understanding practice perceptions of the motivations for PCMH and the capability to undertake change. While this study identified some initial approaches that physician organizations and practices have used to prepare for practice redesign, we need much more information about their effectiveness. [ABSTRACT FROM AUTHOR]

This article focuses on the concepts of the words "nyama" and "heka" in African cultural criticism. Nyama, which is a Mande word for occult power or means, appear to evoke the anti-humanism of post-structuralist theory and is more closely related to ancient ways of thinking about language that are African rather than deconstructive. On the other hand, Heka, which means magical spell and magical rite, is an occult force that infuses the world of things.

Reports by the Institute of Medicine and the Health Care Financing Administration have emphasized that the integration of medical care delivery, evidence-based medicine, and chronic care disease management may play a significant role in improving the quality of care and reducing medical care costs. The specific aim of this project is to assess the impact of an integrated set of care coordination tools and chronic disease management interventions on utilization, cost, and quality of care for a population of beneficiaries who have complementary health coverage through a plan designed to apply proactive medical and disease management processes. The utilization of health care services by the study population was compared to another population from the same geographic service area and covered by a traditional feefor- service indemnity insurance plan that provided few medical or disease management services. Evaluation of the difference in utilization was based on the difference in the cost permember- per-month (PMPM) in a 1-year measurement period, after adjusting for differences in fee schedules, case-mix and healthcare benefit design. After adjustments for both case-mix and benefit differences, the study group is $63 PMPM less costly than the comparison population for all members. Cost differences are largest in the 55-64 and 65 and above age groups. The study group is $115 PMPM lower than the comparison population for the age category of 65 years and older, after adjustments for case-mix and benefits. Health Plan Employer and Data Information Set (HEDIS)–based quality outcomes are near the 90th percentile for most indications. The cost outcomes of a population served by proactive, population-based disease management and complex care management, compared to an unmanaged population, demonstrates the potential of coordinated medical and disease management programs. Further studies utilizing appropriate methodologies would be beneficial. (Disease Management 2006;9:44–55) [ABSTRACT FROM AUTHOR]

Presents a Marxist and geo-thematic criticism of the African literature and the orality-literacy studies in the Sahel. Writing that has been proven to be one of the most significant developments in Marxist literary studies; Pre-literate writing technologies that are not excluded in the meaning of the term primary orality; Approaches that offer an ethical critique of Western imperialism.

Explores author Jacques Derrida's evocation of the Jerusalem figure by contrasting Jewish and Christian approaches to allegorical interpretation. Observation that Derrida's "Specters of Marx" advocates a figurative exegesis or an inherently didactic hermeneutics; Claims of Marxist critics that Derrida relies upon a disguised ontological interpretive system; Readings of Derrida that tend to activate the "Shylock Complex," or the violent conversion of the Jew to logocentric modes of interpretation.

Interviews Mary Brave Bird, a cultural figure in the book and motion picture "Lakota Woman." Role played by the book and movie in Bird's popularity; Bird's interpretation of the Native American Church as a form of Christianity; Views about a racist city in the United States.

Focuses on the historical question of pre-European Igbo being in Chinua Achebe's novel `Things Fall Apart,' especially as it pertains to the larger objectives of contemporary post-colonial theory. Difficulties in bringing the Igbo experience of being into the context of contemporary late capitalist society; Achebe and Western philosophy; Pre-colonial Igbo ontology in `Things Fall Apart.'

Attempts to excavate the historical truth-content within V.S. Naipaul's `A Bend in the River.' Contradictions and crises of material necessity; Novel's situational response to the predicament of modern African history and culture.

Studies Fredric Jameson's Marxist approach to and criticism of Third World literature, offering theoretical coherence and providing strategies both to facilitate teaching of non-Western texts in the First World and to increase production of literature in underdeveloped nations on a global scale. Pedagogical Marxism; Pedagogy of content and form; Comparative studies in situation.

Recounts the frustration and exhilaration experienced by an individual in his attempt to secure an interview with Yambo Ouologuem, the Malian author of `Le devoir de violence.' Circumstances surrounding Ouologuem's elusiveness; Details on the individual's efforts to locate Ouologuem; When and where the interview finally took place; Accounts of Ouologuem's private and professional life; Details on his literary accomplishments.

Explores African writer Ngugi wa Thiongo's works on the oral-aural lifeworld and community values of precolonial African culture. Ngugi's longing for the lost community setting of his childhood in a Gikuyu village; Contradictions of Ngugi's theoretical position about the oral-aural African novel; Lamentation for the loss of immediacy.

Determines whether favorable or adverse selection occurred in a preferred provider organization (PPO) enrollment. Analysis of insurance company payments during the one-year period prior to the enrollment; Health care utilization patterns.

This article focuses on how in 1964 novelist Ngugi wa Thiongo, an unknown writer from Kenya, published his first novel in English, "Weep Not, Child." Ngugi's second novel "The River Between," which predated his first novel in composition, was published shortly thereafter, while Ngugi was still a student at the University of Leeds in England. Ngugi's novel focuses upon British missionary efforts to eradicate Gikuyu circumcision rituals and other customs, which are connected with larger questions of both cultural and economic imperialism.

This article focuses on how the September 1995 issue of the journal "Christianity and Literature," comes at a time when terms like "Third World Literature" and "Postcolonial Studies" have themselves ceased to be disruptive (or "dis-graceful"), functioning instead as officially sanctioned areas of specialization within most literature departments in the United States and elsewhere. By merely adding a few new courses and appropriate faculty, or by simply making room for "new" and "non-traditional" authors to be studied alongside more canonical authors, what has tended to evaporate since the late 1980s is the ethical impetus of previous work in Third World/Postcolonial Studies.

Reports on the isolation of Neisseria gonorrhea that was beta-lactamase negative but highly resistant to penicillin from the synovial fluid of two patients. Medical profile of the patients; Inhibitory concentrations of antibiotics to organisms isolated from patients with disseminated gonococcal infection; Association of chromosomally mediated penicillin resistance with disseminated gonococcal infection.

Background: The growth of managed care presents a challenge to academic medical centers, because the demand for the services of specialists is likely to continue decreasing. We estimated the number of enrollees the University of Michigan Medical Center would need in its health maintenance organization (HMO) system in order to provide revenue equivalent to the total revenue it received for professional specialty care in 1992. Methods: Rates of utilization and payment were based on the medical center's experience with managed care in 1992 in its independent practice association HMO, in which 25,000 members had capitated coverage and received primary and all specialty care from university physicians, and 15,000 members received primary care and most specialty care from physicians outside the university. We assumed that persons not enrolled in Medicare were all enrolled in managed-care plans. Primary care activity was excluded from the calculations of expense, revenue, and numbers of faculty members. Results: If all specialty services were provided by the university to HMO members, all the 21 specialties examined except obstetrics and gynecology and emergency services would require an enrollment of more than 250,000 to support the 1992 level of professional revenue and maintain the number of faculty members. If university services were provided only for referrals from a loosely affiliated network of community physicians in the HMO system, all the 19 specialties examined except plastic surgery would require an HMO enrollment of more than 1 million. In a combined model in which all specialty services were provided to 100,000 HMO members and network referrals were provided to 500,000 members, substantial changes in faculty composition would be needed in all the departments studied. Conclusions: Because of the large number of HMO members required, unless other changes occur, it is unrealistic to expect that the University of Michigan Medical Center could create an HMO or network large enough to support the specialty practice of the current number of faculty members at the 1992 level of financing. (N Engl J Med 1995;333:979-83.) [ABSTRACT FROM AUTHOR]

The article discusses research which aims to describe an approach to patient-centered medical home (PCMH) measurement that has been implemented in Michigan through Blue Cross Blue Shield of Michigan (BCBSM). A field team consisting of health care workers was recruited to conduct site visits with practices to facilitate practice transformation and to validate capability reporting. Results suggest that the measure adequately addresses the specific requirements underlying the BCBSM PCMH program.

BACKGROUND: Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues. RESEARCH DESIGN: Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH. PARTICIPANTS: Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations. KEY RESULTS: We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH. CONCLUSIONS: Providers' motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved. [ABSTRACT FROM AUTHOR]

Objective: To determine if daily dietary supplementation with Chlorella for three months helps normalize body functions, relieve symptoms, and improve quality of life in patients with fibromyalgia syndrome [FMS]. Methods: A total of 43 subjects with FMS were enrolled and randomized such that approximately half consumed 50 Sun ChlorellaTM tablets and 100 mL of liquid Chlorella extract known as Wakasa GoldTM each day for three months and the other half consumed 50 placebo tablets and 100 mL of placebo liquid each day for a comparable period. Neither the patient nor the physician conducting the assessments knew which of the dietary supplements the subject was consuming. Following a one month washout period, subjects crossed-over from Chlorella to placebo or vice versa. Results: Thirty-four subjects completed the entire trial. Six parameters of response were followed while each subject consumed each study diet; subjects answered questions relating to sleep, pain, global well-being, and fatigue while the physician assessed tender point index and global well-being. Subjects were considered as having a positive response to a diet if they demonstrated a 50 percent or more improvement in at least four parameters. Of the 37 FMS subjects who completed the Chlorella arm, seven [19 percent] were responders versus only 3/34 [9 percent] who completed the placebo arm [P = 0.311]. For the four self-assessment parameters, significantly more [21/37 or 57 percent] subjects who completed the Chlorella arm noted a 50 percent or better improvement in at least two parameters while only 10/34 [29 percent] who completed the placebo arm did [P = 0.031]. Patient self-assessment of functional abilities by the Fibromyalgia Impact Questionnaire [FIQ] showed that when they were consuming Chlorella, there was a steady, statistically significant [P = 0.058]. A questionnaire dealing with issues of pain, anxiety, sleep, and gastrointestinal difficulties indicated that while participants were consuming Chlorella, there were stead, statistically significant improvements [P = 0.001] in scores compared to baseline. Comparing the two arms, there was a statistically significant [P = 0.004] improvement in FMS symptoms while the subjects were taking Chlorella. Conclusion: Taken together, the results of this randomized, placebo-controlled, double-blind crossover study leads us to conclude that dietary Chlorella supplementation may be useful in relieving symptoms of FMS. [ABSTRACT FROM PUBLISHER]

Objectives While myeloid-derived suppressor cells (MDSCs) were previously shown to promote a proinflammatory T helper (Th) 17 response in autoimmune conditions, a potential impact of the MDSC-Th17 immune axis on abnormal bone destruction in RA remains largely unknown. Methods We investigated the correlation between the frequency of MDSCs or its subsets and joint destruction in RA patients. The reciprocal actions of patient-derived MDSCs and Th17 cells were studied using osteoclast (OC) differentiation and bone resorption assays in vitro , which were further validated using mouse models of RA. Contribution of MDSCs to osteoclastogenesis and bone erosion in vivo was determined by depletion or transfer of MDSCs. Results Human MDSCs, particularly monocytic MDSCs (M-MDSCs), exhibit inherent OC-differentiating capacity and positively correlate with clinical bone erosion in RA patients. Strikingly, patient-derived M-MDSCs can program Th17 cells towards a pro-osteoclastogenic phenotype, which in return potentiates OC differentiation via the receptor activator of nuclear factor κΒ ligand (RANK-L)-RANK signalling. This enhanced osteolysis driven by the reciprocal actions of M-MDSCs and Th17 cells is further confirmed using mouse models of RA. Selective depletion of M-MDSCs significantly ameliorates osteoclastogenesis and disease severity in arthritic mice, whereas transfer of M-MDSCs aggravates bone erosion associated with increased OCs in recipient mice. Conclusion Our findings highlight the functional plasticity of MDSCs and identify a novel pro-osteoclastogenic pathway governed by interplay between myeloid cells and T lymphocytes in autoimmune RA. [ABSTRACT FROM AUTHOR]

Herein we describe the route scouting and process development efforts toward a green and sustainable synthesis of the HCV NS5b cyclic prodrug nucleoside (CPN) 1. Through the discovery and development of a crystallization-induced dynamic resolution and a novel chemo- and stereo-selective phosphorylation reaction, we eliminated costly chromatographies and protecting group manipulations utilized in the initial approaches to this compound and implemented a highly streamlined and sustainable approach to the target molecule. We demonstrate how these improvements impact the PMI of the API on the kilogram scale and compare our work to the PMI of APIs of similar complexity. [ABSTRACT FROM AUTHOR]

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation. [ABSTRACT FROM AUTHOR]

There has been relatively little empirical evidence about the effects of patient-centered medical home (PCMH) implementation on patient-related outcomes and costs. Using a longitudinal design and a large study group of 2,218 Michigan adult primary care practices, our study examined the following research questions: Is the level of, and change in, implementation of PCMH associated with medical surgical cost, preventive services utilization, and quality of care in the following year? Results indicated that both level and amount of change in practice implementation of PCMH are independently and positively associated with measures of quality of care and use of preventive services, after controlling for a variety of practice, patient cohort, and practice environmental characteristics. Results also indicate that lower overall medical and surgical costs are associated with higher levels of PCMH implementation, although change in PCMH implementation did not achieve statistical significance. [ABSTRACT FROM AUTHOR]

A practicalasymmetric synthesis of the complex fused bis-macrocyclicHCV protease inhibitor MK-6325 (1) is described. Throughthe combination of a high yielding and low catalyst loading ring-closingmetathesis (RCM) to forge the 15-membered macrocycle with an intramolecular sp2–sp3Suzuki–Miyauracross-coupling to append the 18-membered macrocycle, multikilogramaccess to the unique and challenging architecture of MK-6325 (1) has been achieved. [ABSTRACT FROM AUTHOR]

We report a concise, enantio- and diastereoselective route to novel nonsymmetrically substituted N-protected β,β-diaryl-α-amino acids and esters, through the asymmetric hydrogenation of tetrasubstituted olefins, some of the most challenging examples in the field. Stereoselective generation of an E- or Z-enol tosylate, when combined with stereoretentive Suzuki-Miyaura cross-coupling and enantioselective hydrogenation catalyzed by (NBD)2RhBF4 and a Josiphos ligand, allows for full control over the two vicinal stereogenic centers. High yields and excellent enantioselectivities (up to 99% ee) were obtained for a variety of N-acetyl, N-methoxycarbonyl, and N-Boc β,β-diaryldehydroamino acids, containing a diverse and previously unreported series of heterocyclic and aryl substituted groups (24 examples) and allowing access to all four stereoisomers of these valuable building blocks. [ABSTRACT FROM AUTHOR]

The article presents the findings of research which aims to advance the validity of health care research by sharing the empirical experience of 14 research teams in systematically reporting contextual factors important for practice transformation in the U.S. Team members demonstrated the most important contextual factors for their studies. These contextual factors include the practice setting, external environment, and the motivation for research implementation.

In this retrospective clinical trial, we evaluated the effectiveness of low-dose oral methotrexate in the management of bilateral Meniere's disease of immune-mediated origin. At our tertiary-care referral center, we evaluated ten men and eight women who had longstanding bilateral Meniere's disease that had been unresponsive to traditional conservative medical management. Sixteen of these patients had steroid-responsive bilateral Meniere's disease. Two patients had contraindications to steroids, but their clinical and laboratory evaluations were consistent with an immune-mediated process. Patients were treated with 7.5 to 20 mg/week of oral methotrexate. The mean duration of treatment was 16.7 months (range: 8 to 35), with a mean followup of 2 years (range: 9 mo to 5 yr). Changes in clinical symptoms (vertigo, hearing loss, tinnitus, and aural fullness), audiometric changes, and side effects of therapy were evaluated. Vertigo resolved in 14 patients (78%), was substantially alleviated in three patients (17%), and remained unchanged in one patient (6%). Hearing improved in five patients (28%) and stabilized in seven patients (39%). Tinnitus and aural fullness resolved or was relieved in 11 of 17 (65%) and 13 of 14 (93%) patients, respectively. Side effects were minimal and reversible. We conclude that low-dose oral methotrexate is effective and safe for treating bilateral Meniere's disease of immune-mediated origin. In this study, methotrexate alleviated vertiginous symptoms and improved or stabilized hearing in most patients. Low-dose methotrexate can be considered for patients with immune-mediated bilateral Meniere's disease when long-term treatment is required or when a steroid or cyclophosphamide is contraindicated. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and safety of iloprost, a prostacyclin analog, administered intravenously in patients with Raynaud phenomenon secondary to systemic sclerosis.Design: Multicenter, randomized, parallel placebo-controlled, double-blind study.Setting: University medical centers.Patients: 131 patients with systemic sclerosis (101 women, 30 men) ages 20 to 79 years.Intervention: Patients were randomly assigned to receive one of two parallel treatments of five daily sequential, 6-hour intravenous infusions of iloprost (0.5 to 2.0 ng/kg per min) or to receive a similar volume of placebo.Measurements: Frequency of Raynaud attacks, Raynaud severity score, physician's overall rating of treatment effect, and digital cutaneous lesion healing.Results: Of the 131 patients enrolled, 126 completed the 5-day infusion and 114 (87%) completed at least 6 weeks of follow-up. Sixty-four patients were randomly assigned to receive iloprost and 67 patients, to receive placebo. The mean weekly number of Raynaud attacks decreased 39.1% with iloprost and 22.2% with placebo (P = 0.005). In addition, the mean percentage of improvement in a global Raynaud severity score during the entire 9-week follow-up was greater in patients given iloprost (34.8%) than in those receiving placebo (19.7%) (P = 0.011). The physician's overall rating of treatment effect showed greater improvement with iloprost than with placebo at week 6 (52.4% compared with 27.4%; P = 0.008) and week 9 (60.9% compared with 26.9%; P < 0.001). At week 3, 14.6% more patients receiving iloprost had 50% or more lesions heal compared with those given placebo (95% CI, 0.9% to 30%). During the infusion, 59 (92%) of the patients receiving iloprost had one or more side effects compared with 38 (57%) of the patients receiving placebo.Conclusion: Iloprost is effective for the short-term palliation of severe Raynaud phenomenon in patients with systemic sclerosis. [ABSTRACT FROM AUTHOR]

Stereodefined enol tosylates such as (III) and (VI) are prepared and subjected to a stereoretentive Suzuki-Miyaura coupling. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors.Methods: Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context.Results: The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context.Conclusions: These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research. [ABSTRACT FROM AUTHOR]