Thesis (M.S.)--Boston University, Henry M. Goldman School of Graduate Dentistry, 1987 (Dental Public Health). / Includes bibliographical references (leaves 63-66). / The shortage of clinical patients utilizing the services provided at dental schooI clinics is a concern shared by many institutions. In an effort to help increase the patient pool at BostOn University Goldman School of Graduate Dentistry,　dental screening programs were begun in 1983, which focused at targeting　the college student population as prospective clinical patients. The following study was designed to evaluate the effectiveness of the screening programs,　conducted during the fall of 1986, in recruiting dental patients for the school and ascertain specific reasons which expediate or preclude college students from utilizing the dental services at Boston University.　The results of the study demonstrate the moderate success of the screening programs and indicate the need for continued efforts in improving the visibility and organization of the screening sessions at the college institutions participating in the Dental Screening Programs.

ABSTRACT The number of people in immediate need of anti-retroviral treatment (ART) in the southern African region continues to significantly exceed the capacity of health systems to provide it. Approaches to this complex rationing dilemma have evolved in different directions. The ethical concepts of fairness and equity have been suggested as a basis guiding rationing or patient selection processes for ART. The purpose of the study was to examine whether or not such concepts had relevance or operative value for a treatment team providing ART in rural Lesotho. Using an exploratory, single case study design the study found that while concepts of fairness and equity were relevant to the work of the treatment team, patient selection practices did not necessarily reflect what these concepts entail. The idea of fairness as a structured, formalized selection process did not figure in the approach to ART provision at St. Charles. A less formal, ‘first-come-first-served’ approach was adopted. While there was knowledge amongst some team members that social, economic or geographic conditions inhibit individuals and groups from gaining access to ART and that this was inequitable, it was felt that there was little they could do to try to mediate the impact of these conditions. The study findings pose importance questions about the approach to ART programming in resource constrained settings. The findings also question the relevance of trying to achieve fairness and equity when the gap between need for care and capacity to provide it remains so large.

Epilepsy is a common neurological disorder, with potentially devastating consequences, and thus, elucidating the etiology bears immense potential for developing methods for early detection and prevention, targeted treatment options, and overall improvements to quality of life for millions of people worldwide. In 2007, the Epilepsy Phenome/Genome Project (EPGP) set out to compile the largest ever, detailed phenotype-genotype dataset to begin to unravel the complex genetic underpinnings of epilepsy. Over the course of five years, the EPGP sought to enroll a total of 5,250 participants consisting of two cohorts: 1,500 pairs of first-degree relatives with idiopathic generalized epilepsy or localization related epilepsy and 750 triads, or individuals diagnosed with Infantile Spasms, Lennox-Gastaut Syndrome, or certain malformations of cortical development and their unaffected, biological parents. Enrolling an adequate number of eligible research participants is paramount to any study involving human subjects. Despite this, barriers to participant recruitment and accrual persist in a majority of trials, and literature pertaining to methods for overcoming such challenges remains scarce. Like most clinical trials, the EPGP encountered obstacles to participant accrual, and by the end of its first year, net participant enrollment was only 52% of the projected target for that time. To ameliorate this, the EPGP's central administrative team set in motion a multifaceted, dynamic participant recruitment campaign to bolster outreach and increase enrollment numbers. A systematic, retrospective review of the various participant recruitment methods and their respective outcomes was performed. Data was compiled from the EPGP's reporting server, central recruitment database, and other relevant reports and files compiled by the EPGP's administrative team. The various methods implemented by the EPGP to boost participant enrollment include hiring a full-time recruitment director, implementing a National Participant Recruitment Campaign and centralized eligibility pre-screening process, revising the protocol and eligibility criteria, and nearly doubling the size of the network of clinical centers. The centralized screening process facilitated a mechanism for tracking the amount of traffic each recruitment method generated, and this information was analyzed retrospectively. The most successful recruitment methods were found to be those that involved partnerships with healthcare providers and community organizations who have direct and widespread access to the EPGP's target patient population. Less effective methods, in terms of percent of contacts meeting eligibility criteria, were those that did not specifically target people with epilepsy but rather reached a larger demographic. In total, more than 2,000 individuals or families contacted the EPGP centrally, 80% of those underwent eligibility pre-screening with 242 units (579 participants) enrolled in the EPGP as of February 2014. This accounts for 14% of enrollment study-wide, which is analogous to the individual contributions of the EPGP' top enrolling clinical centers. Beyond the recruitment strategies and methods implemented by the campaign, revisions to the EPGP's protocol, modifications to the eligibility criteria, and network expansion resulted in an increase in participant accrual. The number of clinical centers involved in the EPGP was found to positively correlate with participant accrual. Ultimately, a total of 5,442 participants, or 104% of the total enrollment target, were consented to participate. Of those, 4,099 participants, or 78% of the total enrollment target, remain enrolled as of February 28, 2014. The EPGP enrolled more than 75% of target for five of the seven participant types and managed to enroll no less than 50% of target for all participant types. While the results reported are limited by an analysis of the resources required to initiate and carry out the various recruitment methods, the lessons learned during the course of the EPGP may serve to benefit other multi-institutional trials with similar considerations in their recruitment planning. The EPGP's approach to boosting participant accrual was not only successful but also essential to paving the way towards identifying the complex genetic causes and phenotypic manifestations of idiopathic epilepsy syndromes.

The effect of CRT on incidence of AF development in patients with severe HF was explored by comparing 36 patients with conventional indication for the CRT to 36 HF patients without CRT, matched for age, sex and LV systolic function (Publication 5). After a follow up of 3 years, the annual incidence of AF in the CRT group was 2.8%, which was significantly lower than the control group (10.2%). Moreover, the echocardiographic benefit by CRT was compared between these 36 patients with SR and 15 patients with persistent AF. The results showed that the echocardiographic response was similar between the two groups. These findings suggested that CRT may have the potential to reduce AF burden in patients with severe HF and that patients with persistent AF may also benefit from CRT. / The objective of the study (Publication 1) was to assess the feasibility of using non-contact LV mapping to delineate the LV endocardial activation pattern in 7 HF patients in NYHA class III, with low LVEF and wide QRS complex (>120ms). Non-contact mapping was safely performed and there were two endocardial conduction patterns identified, namely homogenous (Type I) and conduction block (Type II). The second part of the study (Publication 2) was to determine the implication of these two distinct activation patterns to echocardiographic and clinical response to CRT. 23 patients in NYHA class III, with LVEF <35% and QRS duration >120ms were recruited in this study. 15 patients had Type II pattern and 8 Type I. The QRS duration between the two types of conduction patterns were comparable. Patients with Type II pattern had a more favourable echocardiographic and clinical response to CRT than those with Type I. It was concluded that, despite the similar QRS duration between the two types of LV endocardial activation patterns, patients with Type II pattern had a more favourable response to CRT. / The significance of baseline renal function in CRT was assessed in 85 consecutive patients with conventional indication for the CRT (Publication 7). There was no significant relationship between baseline renal function and significant LV reverse remodeling after CRT, suggesting baseline renal insufficiency probably would not affect the response to CRT. (Abstract shortened by UMI.) / This study (Publication 3) was to determine the effect of CRT in patients with narrow QRS complex and evidence of mechanical dyssynchrony as determined by TDI. 51 patients in NYHA class III or IV, with LV ejection fraction <35%, and QRS duration <120ms were recruited for the CRT. The effect of the device therapy on LV systolic function in this cohort was compared to 51 patients who fulfilled the current criteria with wide QRS complex. CRT significantly improved the LV systolic function, NYHA class and exercise capacity in those with narrow complex to a similar extent in those with wide complex. With co-existing mechanical dyssynchrony determined by TDI, patients in both narrow and wide QRS complex groups showed more favourable response to CRT than those without significant mechanical dyssynchrony. This confirmed that QRS was a poor marker of mechanical dyssynchrony and the current selection criteria are probably not adequate to include more potential responders to the therapy. / This study (Publication 4) was to determine the role of optimal medical therapy in CRT recipients before implantation. The echocardiographic and clinical effect of CRT in 30 patients without the optimal combination of ACEi or ARB and beta-blockers was compared to 30 patients matched for age, sex, NYHA class and HF etiology. Patients with optimal medical therapy had significantly better echocardiographic and clinical response to CRT. The results confirmed that optimal medical therapy is necessary to achieve maximal response by CRT. / This study (Publication 6) was to determine if patients with moderate LV systolic function and wide QRS complex would benefit from the CRT. Significant improvement in LV systolic function was observed in 15 patients with LVEF between 35 and 45%, NYHA class III and QRS duration >120ms after CRT, suggesting that presence of LV systolic dysfunction and cardiac dyssynchrony may be the major determining factors for favourable CRT response. Therefore, patients with less advanced HF may also benefit from the CRT. / "May 2007." / Adviser: Yu Cheuk Man. / Source: Dissertation Abstracts International, Volume: 69-08, Section: B, page: 4657. / Thesis (M.D.)--Chinese University of Hong Kong, 2007. / Includes bibliographical references (p. 133-151). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / School code: 1307.

Thesis (Ph. D.)--University of Alabama at Birmingham, School of Education, 1998. / eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 103-109).

Thesis (Ph. D.)--University of Alabama at Birmingham, School of Education, 1998. / eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 103-109).

The aim of this thesis was to establish the long-term outcomes of the Oxford medial Unicompartmental Knee Arthroplasty (OUKA), define patient selection criteria and to develop and externally validate an evidence based method of patient selection for this procedure. In the hands of the developer surgeons, outcomes following medial OUKA were found to be good with an implant survival of 94% (95%CI 92 to 96) at ten-years and 91% (95%CI 83 to 98) at fifteen-years. Across the published literature, however, variation in outcomes was observed with a meta-analysis of published series of OUKA finding estimates of ten-year survival ranging from 57% to 100%, mean 88% (95%CI 85 to 90). It was identified that both increased surgical caseload (volume) and increased surgical usage (proportion of primary knee arthroplasty that are OUKA), a surrogate marker of indications, were associated with improved outcomes. Surgical usage, however, was more important, with good results following OUKA seen with high surgical usage, representing broad indications, independent of the surgical volume. This finding, coupled with differences in patient demographics and failure mechanisms between usage groups, highlighted that differences in indications for OUKA may explain the variability in outcomes observed. One reason surgeons may have a low usage is if they apply previously recommended patient factor contraindications based on age (<60 years), weight (≥82kg) and activity level (high activity). When disease factors are standardised, however, it was found that patients with these previously reported contraindications often actually did better than those without, and outcomes of knees implanted where all these factors were present were as good as where none were present. Therefore, the decision to proceed with OUKA should be based on the pathoanatomy of disease. Optimal candidates for OUKA should have full-thickness cartilage loss, with bone on bone arthritis, in the medial compartment, as knees with partial thickness cartilage loss were found to have worse functional outcomes and almost three-times the reoperation rate, predominantly for unexplained pain. Provided there was full-thickness preserved cartilage laterally and functionally normal ligaments, the presence of lateral osteophytes and the macroscopic status of the anterior cruciate ligament was not found to influence outcomes, nor did the presence of patellofemoral joint disease (with the exception of lateral facet disease with bone loss and grooving) or anterior knee pain. The pathoanatomy of disease can be identified radiologically, however, standing knee radiograph were found to perform poorly. To identify medial compartment full-thickness cartilage loss either a varus stress radiograph or fixed flexion radiograph, both at 20° flexion and aligned to the joint surface, were identified as the optimum views. To confirm preserved lateral compartment full-thickness cartilage a valgus stress radiograph at 20° flexion, aligned to the joint surface, was identified as the most appropriate technique. As stress radiographs are time and resource consuming, a novel stress device was developed in line with the IDEAL-D framework and validated against the gold standard of manual, clinician performed stress radiographs, as well as independently tested in clinical practice. Finally, to simplify patient selection, an atlas based Decision Aid, combined with a structured radiographic assessment, was developed and externally validated with an accuracy of over 90% at identifying suitability for OUKA. The routine use of this approach would be expected to standardise patient selection and ultimately translate into improved long-term outcomes.

No description available.

INTRODUÇÃO: A recuperação motora é o principal foco dos estudos sobre reabilitação de indivíduos com acidente vascular cerebral (AVC), já que a hemiparesia ocorre em 75% dos casos. No intuito de diminuir o impacto da paresia do membro superior na funcionalidade, diversas modalidades de tratamento têm sido estudadas. O interesse pelo uso de técnicas de neuroestimulação não invasivas, como a estimulação magnética transcraniana repetitiva (EMTr), cresceu de forma acelerada nas últimas décadas. Apesar de cerca de dois terços dos AVCs ocorrerem em países de baixa ou média renda e em desenvolvimento, a maior parte dos estudos sobre o emprego da EMTr na reabilitação após AVC tem sido realizada em países desenvolvidos. Dificuldades de recrutamento são comuns em ensaios clínicos ou estudos de comprovação de conceitos ligados a reabilitação em geral, ou ao uso da EMTr em pacientes com AVC em particular, mesmo em países desenvolvidos. Este trabalho teve como objetivo descrever as barreiras para a inclusão de participantes em um protocolo de reabilitação do membro superior utilizando EMTr em pacientes com AVC, realizado em nosso meio. CASUÍSTICA E MÉTODO: Este estudo foi realizado como parte de um ensaio clínico aleatorizado, controlado e duplo-cego conduzido no Hospital das Clínicas da Universidade de São Paulo. Foi realizada uma avaliação prospectiva da frequência dos motivos de não inclusão de pacientes para um protocolo de tratamento com EMTr de baixa frequência do hemisfério não afetado, em pacientes com paresia da mão após AVC. RESULTADOS: A mediana da idade dos indivíduos triados foi de 63 anos (intervalo, 14-102 anos). Houve leve predomínio do sexo masculino (57%), e 78% dos indivíduos foram considerados brancos. Dos 673 indivíduos triados, foram coletadas informações completas de 571 pacientes. Destes, apenas 32 (5,6%) foram incluídos. O critério de não inclusão mais frequente foi lesão afetando mais que 50% do território da artéria carótida interna (53,4%). As principais razões para exclusão foram AVC recorrente (45,4%), condições clínicas não controladas (17,2%) e presença de contraindicações para a EMT (11,7%). CONCLUSÕES: Considerando que 85% dos AVCs ocorrem nos países em desenvolvimento ou subdesenvolvidos onde a taxa de recorrência é alta, protocolos de reabilitação com critérios de exclusão menos restritivos são necessários para torná-los mais adequados para a população estudada / INTRODUCTION: Considering that hemiparesis occurs in 75% of patients with stroke, motor recovery is the main goal of rehabilitation research protocols. Different modalities of treatment have been developed to minimize the burden of upper limb paresis. The number of studies concerning the use of transcranial magnetic stimulation (TMS) as a potential tool for stroke rehabilitation has grown in the last decades. In spite of the fact that two-thirds of the strokes worldwide occur in low- or middle-income countries, most of TMS stroke rehabilitation studies have been performed in high-income countries. Recruitment barriers are a common issue in clinical trials or proof-of-principle studies related to rehabilitation in patients with stroke, even in developed countries. The main goal of this study was to describe the barriers to participant inclusion in an upper limb rehabilitation protocol with TMS in patients with stroke in Brazil. METHODS: This study was developed as part of a randomized clinical trial conducted at Hospital das Clínicas of the University of São Paulo, Brazil. We analyzed the frequency of reasons for participant non-inclusion in a proof-of-principle rehabilitation trial that applied low-frequency TMS to the non-affected hemisphere of patients that presented hand paresis after stroke. RESULTS: The median age of patients screened for the protocol was 63 years (interval, 14-102 years). Seventy-eight percent of them were White and 57% were male. From the 673 screened patients, complete data were collected from 571 participants but only 32 (5.6%) of them were included. The inclusion criterion that was fulfilled less frequently was a lesion affecting more than 50% of the internal carotid artery territory (53.4%). The three most frequent exclusion criteria were multiple strokes (45.4%), uncontrolled clinical conditions (17.2%) and contraindications to TMS (11.7%). CONCLUSION: Considering that 85% of strokes occur in low- and middle-income countries, where the incidence of recurrent stroke is high, rehabilitation protocols with less stringent exclusion criteria are suggested, in order to make them applicable to more patients

Os sujeitos da pesquisa, em razão de seu estado de vulnerabilidade, reclamam por cuidados éticos e jurídicos. Esta tutela deve anteceder ao status em que o sujeito da pesquisa ainda não está caracterizado como tal, ou seja, quando, como paciente, participa de seleções para integrar experimentos, no caso, promovidos por Instituições de Ensino Superior públicas (IES). No aspecto jurídico, pacientes, sujeitos da pesquisa e comunidade científica foram colocados sob a égide do Código de Defesa do Consumidor a fim de se apurar a tutela desse diploma legal sobre referidas figuras. Em face dessa abordagem ética e jurídica, este estudo teve como objetivo, por meio de uma revista da literatura, desenvolver uma análise crítica sobre a formatação atual utilizada pelas IES pública para recrutamento de sujeitos da pesquisa, através de seus pacientes pré-concebidos; mensurar a importância da formalização de edital pela IES pública nesse contexto de recrutamento. Analisar, ainda, a dicotomia jurídica desenvolvida em torno do Código de Defesa do Consumidor pertinente ao paciente atendido pela IES Pública, por intermédio do SUS e o paciente atendido pela IES privada não submetido ao SUS. Por fim, conferir sob a ótica do Código de Defesa do Consumidor a responsabilidade civil da comunidade científica em decorrência de danos causados ao sujeito da pesquisa. Trata-se de um estudo exploratório e descritivo, com abordagem qualitativa desenvolvida a partir de pesquisas em material existente na literatura nacional e internacional, pertinente à pesquisa envolvendo seres humanos, a sua forma de recrutamento e a responsabilidade civil suscitada em face dos sistemas de saúde público e privado e, não menos, sobre a relação jurídica desenvolvida entre sujeito da pesquisa e comunidade científica. Especificamente, a fundamentação teórica se deu sobre a doutrina da bioética, do biodireito e da ordem jurisdicional, com fomento da legislação brasileira. Foram utilizadas as bases de dados Pubmed, Scielo, Lilacs, Google Acadêmico, Google e Tribunais de Justiça, com a combinação dos seguintes descritores: seleção de pacientes, sujeitos da pesquisa, defesa do consumidor, ética em pesquisa e academia e institutos. Considera-se, ao final, que na IES pública o recrutamento de sujeitos da pesquisa não deve configurar coerção tácita, sendo superlativa a valoração de conceitos éticos intrínsecos à dignidade humana, restando-lhe, ainda a observância de princípios constitucionais referente à administração pública. Nesse âmbito público, a necessidade de edital é requisito formalístico, imperioso para recrutamento de sujeito da pesquisa. Tanto o sistema público de saúde, promovido pela IES pública, como o sistema privado de saúde, promovido pela IES privada, estão sob a tutela do Código de Defesa do Consumidor; ainda devendo ficar sob o pálio deste diploma legal a relação jurídica desenvolvida entre sujeito da pesquisa e comunidade científica. / Human research subjects, due to their vulnerability status, claim to ethical and legal care. This protection must precede the status in which the research subject is not characterized as such, that is when, as a patient, attends selections to integrate experiments in the case, promoted by Public Higher Education Institutions (HEI). In the legal aspect, patients, research subjects and scientific community were placed under the aegis of the Consumer Protection Code in order to establish the tutelage of this statute on those figures. Faced with this ethical and legal approach, this study aimed, through a literature review, develop a critical analysis of the current format used by public HEIs to the recruitment of research subjects, through their predesigned patients; measure the importance of the announcement of the formal public HEIs in this recruitment context. Also, analyze the legal dichotomy developed around the Consumer Protection Code relevant to patients attended by public HEIs, through the Brazilian Public System of Health (BSH) and the patient treated by the private institution not subjected to the BSH. Finally, check, from the perspective of the Consumer Protection Code, the liability of the scientific community due to damages caused to the research subject. This is an exploratory and descriptive study with qualitative approach, developed from research into existing material in national and international literature, relevant to researches involving human beings, their form of recruitment and liability raised in the face of public and private system of health and, not least, on the legal relationship developed between the research subject and the scientific community. Specifically, the theoretical foundation took over the doctrine of bioethics, the bio law and court order, fostering by the Brazilian law. Databases used were Pubmed, Scielo, Lilacs, Google Scholar, Google and Courts of Justice, with the combination of the following descriptors: Patient Selection, Research Subjects, Consumer Advocacy, Ethics, Research and Academies and Institutes. In the end, is considered that in the public HEI, the research subject recruitment should not configure tacit coercion, being superlative the valuation of intrinsic ethical concepts of human dignity, leaving him, yet compliance with constitutional principles relating to public administration. In this public sphere, the need for notice is formalistic requirement imperative for the recruitment of research subjects. Both systems of health, as public promoted by public HEIs, as the private promoted by the private HEIs are under the authority of the Consumer Protection Code; should still be under the canopy of this instrument the legal status developed between the research subject and the scientific community.