Research Topics: Medical Case Study

TLC-Asthma :An Integrated Information System for Patient-centered Monitoring,Case Management, and Point-of-Care Decision Support

TLC-Asthma: An Integrated Information System for Patient-centered Monitoring, Case Management, and Point-of-Care Decision Support   Abstract A great deal of successful work has been done in the area of EMR development, implementation, and evaluation. Less work has been done in the area of automated systems for patients. Efforts to link data at multiple levels – the patient, the case manager, and the clinician have been rudimentary to-date. In this paper we present a model information system that integrates patient health information across multiple domains to support the monitoring and care of children with persistent asthma. The system has been developed for use in a multi-specialty group practice and includes three primary components: 1) a patient-centered telephone-linked communication system; 2) a web-based alert reporting and nurse case-management system; and 3) EMR-based provider communication to support clinical decision making at the point-of-care. The system offers a model for a new level of connectivity for health information that supports customized monitoring, IT-enabled nurse case-managers, and the delivery of longitudinal data to clinicians to support the care of children with persistent asthma. Systems like the one described are well -suited, perhaps essential, technologies for the care of children and adults with chronic conditions such as asthma. INTRODUCTION The application of information technology to medical care involving patients as users has traditionally relied on stand-alone desktop computers in patient homes.1,2 More recently, advances in telecommunications technology have made it possible to link patients in their homes to computer networks via computer, telephone, and other devices3 – creating new opportunities for the application of information science to support the ambulatory care of patients and consumers. These new technologies are especially well-suited for the monitoring and care of chronic conditions such as asthma. Asthma is the most common chronic disease of childhood and its prevalence has been increasing in the U.S.4 Despite the success of modern pharmacotherapy, asthma care in the U.S. is often sub-optimal. Anti-inflammatory drugs have been under-prescribed by clinicians and under-used by patients.5 Patient self-monitoring of peak expiratory flow rate (PEFR) using a peak flow meter (PFM) as recommended by the NAEP and others is frequently not done. In addition, asthma severity is often under-diagnosed due to a lack of information regarding symptoms of persistent disease outside the clinical encounter. Efforts to improve the quality of asthma care have focused primarily on the areas of patient education and case management. However, these approaches are labor intensive and costly, and thus are practical only for the most severe patients with asthma. Furthermore, both approaches are often limited by the lack of information regarding asthma symptoms at home. Computer-based telecommunication technology offers great potential as a cost-effective tool for 1) monitoring asthma symptoms and patient knowledge outside the clinical encounter; 2) providing enhanced education and case management when problems are identified; and 3) EMR-based provider communication to support clinical decision making at the point-of-care. In this paper, we describe an integrated information system developed to link patients, case managers, and their primary clinician in an effort to improve the quality of asthma outcomes and care using: 1) a telephone linked patient communications system; 2) a Web-based alert reporting and nurse case management system; 3) transfer of patient reported information to primary care clinicians; and 4) use of EMR-based reporting for clinical decision making at the point-of-care. The system has been developed for use within a multi-specialty group practice in eastern-Massachusetts. Our goals are to describe the design of the system, highlight some of the unique features and considerations of a computer-based telecommunication system for children, and offer a model for an integrated information system that combines patient-centered monitoring and education, Web-bas ed case management, and EMR-based reporting and decision support (Figure 1). Figure 1 TLC Asthma System Architecture   PATIENT-CENTERED MONITORING AND EDUCATION The TLC (Telephone-Linked Communications) system is a computer-based telecommunications system developed to be an at-home monitor, educator and counselor for patients with chronic health conditions.6,7 TLC carries out totally automated telephone conversations with patients. During TLC telephone conversations, the system speaks to patients using computer-controlled digitized human speech. The patients, in turn, communicate with TLC by pressing the keys on their telephone keypad or by speaking into the telephone receiver. During TLC conversations, TLC asks the patients questions to monitor their health conditions; it also provides education and behavioral counseling for targeted health-related behaviors such as medication taking, diet and exercise. After each conversation, TLC stores the information the user has communicated in a database. Either the patient or TLC may initiate a conversation. Should the patient fail to call when expected, TLC will call the patient. In addition to questioning the patient, TLC provides education and behavioral reinforcement, such as counseling on how to take medications at prescribed times. TLC conversations were designed to emulate telephone conversations between patients and health professionals. A typical conversation lasts between three and five minutes, depending on the number and complexity of the topics addressed and the user’s responses. The telephony system runs on a Windows NT computer using a D120x Intel/Dialogic board to interpret DTMF tones and play compressed voice files. The system was programmed in Visual Basic and Visual Voice platform. Automated faxing and reporting features are developed in Visual Basic and faxing is provided by FacSys Fax Server. Data is stored in an Oracle 9i database. TLC-Asthma is designed for use by children between the ages of five and sixteen with mild -moderate persistent asthma and their parents. Educational materials and scripts have been prepared for four groups based on current grade in school (K-1, 2–3, 4–6, 7+) to provide material appropriate to the cognitive/developmental stages of children and the differing roles that parents play in disease management at these different ages. TLC-Asthma converses with both the patient (the child) and a responsible parent or guardian, in separate conversations. Both child and parent receive customized asthma education during TLC conversations. For example, in a particular TLC-Asthma conversation, education regarding environmental control is limited to a discussion of dust avoidance when addressed to the young child, but is deeper and broader when directed to the parent, including information on the life cycle requirements of dust mites (e.g., high humidity, skin scales, etc.) and information on how to obtain and use covering materials. The content of TLC-Asthma conversations is based on the NAEP Guidelines for the Diagnosis and Management of Asthma,8 and educational material written for the NHLBI’s Childhood Asthma Management Project (CAMP), an on -going multi-center clinical trial of anti- inflammatory therapy. Content areas for monitoring and education have been developed and are addressed on multiple occasions during sequential cycles. The monitoring components include: severity-treatment mismatch, assessment of the use of a home peak- flow meter (PFM), symptom level, functional status, and knowledge and adherence to the prescribed medication regimen. The educational components include: 1) recognition of asthma symptoms, particularly those that might indicate an exacerbation; 2) potential triggers of asthma and steps that should be taken to mitigate them; 3) exacerbations and how to deal with them; 4) medication use; 5) pretreatment; and 6) appropriate use of the health care system including regular office visits and urgent care. TLC -Asthma educates by first assessing knowledge and then providing targeted education as r equired. For all calls, the system inquires whether the child has had any changes in his asthma symptoms and if so, which symptoms changed and their frequency. If the child has had a change in symptoms, the conversation moves to a targeted inquiry of potential triggers of the worsening symptoms. For all calls, TLC-Asthma also inquires about functioning. Finally, in each weekly conversation, TLC -Asthma asks several questions related to asthma knowledge. Each important piece of information is put in a form of a yes-no question. In response to the user’s answer, the system provides constructive educational feedback to help the user learn. The educational material is presented in order of its relative importance (e.g., medication use and actions to take for exacerbations are covered first). At the end of each TLC-Asthma conversation, the system summarizes the most important points (take home messages) for the child, gives positive reinforcement for the child’s efforts in self -care, reassures the child about his/her health status, and reminds the child to call the next week. Several age-appropriate sports and entertainment celebrities have volunteered to provide voice recordings to better engage children during the computer-based interviews. A WEB -BASED NURSE ALERT REPORTI NG AND ASTHMA CASE MANAGEMENT TOOL During TLC-Asthma interviews, the system monitors each conversation for potential clinical problems or issues and, when identified, generates a system alert. Alerts are grouped into one of two levels . The system is capable of generating alerts for a broad range of clinical problems. Level 1 alerts are generated for responses that require immediate attention. For example, when a child or parent reports significantly reduced peak flow monitor readings (less then 50% of predicted) and lack of response to reliever meds, a Level 1 alert is generated. The patient is told to seek medical care immediately. For all Level 1 alerts, a fax is immediately sent to a dedicated fax line and the TLC system then calls a 24-hour phone number to notify responsible clinical personnel. Level 2 alerts cover a wide range of items ranging from medication supply and compliance to knowledge of key asthma content. Level 2 alerts are sent to the TLC Alert Reporting and Documentation System to be reviewed by the TLC-Asthma nurse. Alerts are viewed in the TLC-Asthma Alert Log (Figure 2). Figure 2 The TLC Alert Log The TLC Alert Reporting system has been programmed in Java, and uses a replicated Web -accessible database. Nurses using the system are able to see all alerts from a given TLC-Asthma interview, group them, provide documentation of response, create and customize a summary note and flag the note for transfer to the patient’s EMR. The nurse can also use the software to view the patient’s “TLC-Record” which includes all responses to TLC-interviews, summaries of previous alerts and responses, and a view of the Summary Report described below. TLC-ASTHMA NURSE ROLE The TLC-Asthma nurse is in essence, an IT enabled nurse case manager. The role of this nurse has been adapted from asthma case management systems already in existence.9,10 There are, however, important differences in the role of TLC nurses. Nurse case managers traditionally educate the child and the parent about asthma and the role of both the child and the parent in the management of the child’s asthma at home. They monitor the child’s asthma by periodic telephone calls as well as through office visits. The TLC-Asthma nurse provides basic asthma education at the beginning of the child and parent’s participation in the study. Subsequent asthma education will take place during TLC conversations. The TLC-Asthma nurse does not have the responsibility for making regular telephone and office contacts with the child and/or parent in order to monitor the status of the child’s asthma. This function is taken over by the TLC system. The presence of IT support, however, allows much closer monitoring of a child’s asthma and the early detection of items in need of attention. For example, the TLC-Asthma nurse will know that a patient has no controller medicine at home well before the next scheduled visit to a primary care clinician or periodic phone call. The TLC nurse is responsible for two responsibilities that are specific to the TLC system. First, the nurse will contact the child and/or parent if either does not use TLC on a regular basis. Second, the TLC-Asthma nurse will monitor the TLC-Asthma Alert Log and document alert responses. INTEGRATING PATIENT-CENTERED INFORMATION, CASE MANAGEMENT, AND THE EMR Primary care providers for each TLC-Asthma patient receive documentation of all alert responses by the TLC-Asthma nurse. These reports include detailed descriptions of each alert, followed by nursing documentation of case-management interventions performed. Reports are sent to each provider via the internal EMR (EpiCare,EPIC Software Systems, Inc.) messaging system. In addition, key data gathered during TLC-Asthma telephone i nterviews is transferred to the EMR nightly via secure file transfer. These data are used to build a “TLC Summary Report” (Figure 3). The purpose of this report is to support clinical decision making by the TLC-Asthma patient’s primary clinician. The report contains an updated asthma medication list and longitudinal data related to acute symptom frequency, reliever medication use, long-term symptoms and functioning, and objective asthma assessment measures. This report is updated nightly and available via the EMR at the time care is delivered by the primary care clinician. Clinicians are encouraged to review Summary Reports via in-service training, and prompts embedded in the text of every alert response note. Figure 3 Sample TLC-Asthma Summary Report   CONCLUSIONS A great deal of successful work has been done in the area of EMR development, implementation, and evaluation. Less work has been done in the area of automated systems for monitoring patients with chronic conditions and alert responsible clinicians when problems are detected. Efforts to link data at multiple levels – the patient, the case manager, and the clinician have been rudimentary to-date. There is a tremendous need to provide effective, low-cost education and monitoring for the large numbers of children with persistent asthma who do not have severe disease, but who are persistently symptomatic. Equally important is the need for tools to more effectively support nurse case managers in their efforts to identify patients in need of their services. The TLC-Asthma system offers a model for a new level of connectivity for health information and a new level of interactivity for patients. The system supports highly customized delivery of health information to monitor and support the needs of children at different developmental stages. The system is also closely linked to the case managers who, with computer-assistance, can better prioritize and customize care for the needs of individual children. Finally, the system is capable of monitoring multiple factors at a frequency that could not be performed in most settings. The TLC-Asthma system is currently being evaluated in a randomized clinical trial of 300 children with persistent asthma. A cost-effectiveness analysis will be conducted at the completion of the study. If found to be effective, and affordable, systems like the one described in this paper will be well-suited, perhaps essential, technologies for the care of children and adults with chronic conditions such as asthma. Credit:ivythesis.typepad.com

TLC-Asthma :An Integrated Information System for Patient-centered Monitoring,Case Management, and Point-of-Care Decision Support

TLC-Asthma: An Integrated Information System for Patient-centered Monitoring, Case Management, and Point-of-Care Decision Support ...

ESSAY ON THE BRAIN

The brain has three main divisions: (1) the cerebrum, (2) the cerebellum, and (3) the brain stem. Each part consists chiefly of nerve cells called neurons, and supporting cells called glia. The cerebrum makes up about 85 percent of the weight of the human brain. A large groove called the longitudinal fissure divides the cerebrum into halves called the left cerebral hemisphere and the right cerebral hemisphere. The hemispheres are connected by bundles of nerve fibres, the largest of which is the corpus callosum. Each hemisphere, in turn, is divided into four lobes (regions). Each lobe has the same name as the bone of the skull lies above it. The lobes are: (1) the frontal lobe, at the front; (2) the temporal lobe, at the lower side; (3) the parietal lobe, in the middle; and (4) the occipital lobe, at the rear. Fissures in the cerebral cortex form the boundaries between the lobes. The two major fissures are the central fissure and the lateral fissure. The cerebellum is the part of the brain most responsible for balance, posture, and the coordination of movement. It lies below the back part of the cerebrum. The cerebellum consists of a large mass of closely packed folia. The cerebellum has a right hemisphere and a left hemisphere, with a finger-shaped structure called the vermis in the middle.  The brain stem is a stalk like structure that connects the cerebrum with the spinal cord. The bottom part of the brain stem is called the medulla oblongata or medulla. The medulla has nerve centers that control breathing, heartbeat, and many other body processes essential to life. At the upper end of the brain stem are the hypothalamus and the thalamus. There are actually two thalami, one on the left side of the brain stem and one on the right side. Each thalamus receives nerve impulses from various parts of the body and routes them to the appropriate areas of the cerebral cortex. The thalami also relay impulses from one part of the brain to another. The hypothalamus regulates body temperature, hunger, and other internal conditions. It also controls the activity of the nearby pituitary gland, the master gland of the body.  The endocrine system links the brain to the organs that control body metabolism, growth and development, and reproduction is a control system of ductless endocrine glands that secrete chemical messengers called hormones that circulate within the body via the bloodstream. The limbic system operates by influencing the endocrine system and the autonomic nervous system. The limbic system is highly interconnected with a structure known as the nucleus accumbens, commonly called the brain’s pleasure center. The nucleus accumbens plays a role in sexual arousal and the “high” derived from certain recreational drugs. These responses are heavily modulated by dopaminergic projections from the limbic system. Rats with metal electrodes implanted into their nucleus accumbens will repeatedly press a lever which activates this region, and will do so in preference over food and water, eventually dying from exhaustion. Injuries, diseases, and inherited disorders can damage the brain. However, the seriousness of brain damage depends chiefly on the area of the brain involved rather than on the cause of the damage. Stroke is the most common serious disorder of the brain. A stroke occurs when the blood supply to part of the brain is cut off. Nerve cells in the affected areas die, and the victim may lose the ability to carry out functions controlled by those areas. Tumors are abnormal growths that can cause severe brain damage. The effects of a tumor depend on its size and location. A tumor may destroy brain cells in the area surrounding it. As the tumor grows, it also creates pressure, which may damage the other areas of the brain or at least interfere with their normal function. A number of diseases caused by bacteria or viruses can damage the brain. The most common of these infectious diseases are encephalitis and meningitis, either of which may be caused by bacteria or viruses. Encephalitis is an inflammation of the brain. Meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord. Chorea is a disease of the brain that mainly affects children from 7 to 15 years old. Most cases of chorea occur with rheumatic fever and may be caused by the same bacteria which cause that disease. A virus disease called poliomyelitis attacks the brain and spinal cord.   References:   Credit:ivythesis.typepad.com

ESSAY ON THE BRAIN

The brain has three main divisions: (1) the cerebrum, (2) the cerebellum, and (3) the brain stem. Each part consists chiefly of nerve c...

ESSAY ON THE BRAIN

The brain is the organ of thought and feeling. As others say, having a brain is what makes the human to be different from other creatures of God. Parts of the brain include the three main divisions; the cerebrum which is the front part of the brain which forms about 85% of the weight of human brain, the cerebellum is found at the back area of the cerebrum which is in charge of the balance, posture and coordination of movement, and the brain stem which attach the spinal cord and the cerebrum. Other parts of the brain also include the hemisphere which is separated into four lobes: the frontal lobe, the temporal, the parietal and the occipital lobe. The medulla or the medulla oblongata is another part of the brain that controls the breathing, heartbeat, and other works of the brain that are vital to life. On the other hand, the thalami receive brain impulses while the hypothalamus regulates body temperature, hunger and internal conditions. Endocrine, limbic system and nucleus accumbens are also connected the brain to other organs of the body. Credit:ivythesis.typepad.com

ESSAY ON THE BRAIN

The brain is the organ of thought and feeling. As others say, having a brain is what makes the human to be different from other creatures ...

Radiation, Research Involving

Radiation, Research Involving Use of radioactive materials Radioactivity and radiation are natural phenomena to which all humans are continuously exposed. This includes traces of radioactive material in the earth’s crust, radioactive gases in the air that we breathe, natural radioactive potassium in the body from food and drink and cosmic rays from space. This is often referred to as ‘background radiation’. Diagnostic medical procedures are the most likely source of additional radiation exposure. Radiation may be delivered by X-rays passing through the body during diagnostic radiological procedures. Alternatively, internal exposure may occur during ‘nuclear medicine’ procedures, which use injected or ingested radioactive materials, that is, radiopharmaceuticals, to measure or image metabolic processes. At one extreme, very high levels of radiation dose have clearly defined adverse effects. At the other extreme, higher ‘background’ radiation levels in certain geographical sites, or relatively small increases above background levels of exposures to radiation, have no proven adverse effects and may possibly even be beneficial. This presents some difficulties for Human Research Ethics Committees (HRECs) in evaluating the relative risks and benefits of research protocols using radioactive materials or X-rays. Nevertheless, prudent practice dictates the use of conservative radiation risk estimates, which assume that the negative effects from radiation may increase in a ‘straight line’ with the increase in the level of radiation dose from the very lowest to highest levels, with no assumed threshold below which there is no adverse effect at all. This assumption is known as the ‘linear no-threshold hypothesis’. The international radiation protection community has, over many years, developed and applied the ALARA principle in developing guidelines that balance the benefits of radiation exposures against possible risks. This principle states that human exposures to radiation should be ‘As Low As Reasonably Achievable, with economic and social considerations taken into account’. [Footnote 124] Within the context of medical and research exposures, this is usually taken to mean that each individual should receive no more radiation than is necessary to obtain reliable information and that no more research participants should be irradiated than is necessary to answer a particular scientific question. It is also taken to mean that special steps should be taken to minimise radiation exposures to people with elevated risk of adverse effects from radiation based on pregnancy or youth. [Top of Page ] Measurement and regulation of radiation exposure For each research protocol that includes exposure of research participants to radiation, the dose of radiation exposure should be calculated by an appropriate institutional or external radiation physicist/radiation safety officer. Radiation dose should be expressed in the following SI unit: 1 milliSievert (mSv) effective dose. This unit takes into account the type, intensity and duration of radiation, the amount and type of body tissues irradiated and the different radiation sensitivity of the irradiated tissues. The average natural background dose rate in Australia is 2 mSv/year. Medical exposures contribute about another 0.50.7 mSv/year. The current recommended limit for occupational exposure in Australia is 20mSv effective dose per year averaged over five consecutive years. [Footnote 125] The NHMRC has recommended dose constraints for adult volunteers in medical research of 5 mSv in one year, with a maximum cumulative effective dose of 10 mSv over five years. [Footnote 126] This places an obligation on researchers to develop mechanisms to ensure that participants who are close to these dose limits do not inadvertently exceed the five-year limit by entering subsequent research studies involving radiation. It is also recommended that in children the total cumulative effective dose to age 18 years be restricted to a total of 5 mSv. [Footnote 127] These recommended exposure limits do not include medical exposures that are considered likely to be medically beneficial to the patient, or to be part of good medical care. In each State and Territory of Australia, the Radiation Safety Section of the departments of health regulates radiation exposure to the public. All States, except South Australia, legally require the Radiation Safety Section of the State Department of Health to review and approve any research protocol that proposes to deliver any quantity of ionising radiation to totally normal healthy volunteers before final approval can be granted by an HREC. In South Australia, prior approval of such protocols by the State is not required, although the Radiation Protection Branch must be notified within seven days of approval by an HREC. Furthermore, legally required radiation exposure limits in South Australia are significantly less for normal volunteers aged under 18 years (0.5 mSv) and under 2 years (0.1 mSv) than the upper limit permitted by NHMRC Guidelines. Ethics committees assessing research proposals involving exposure of participants to ionising radiation must follow the requirements of State and Territory legislation and the NHMRC Recommendations for Limiting Exposure to Ionising Radiation (1995). [Footnote 128] In addition, Radiation Safety authorities are available to consult on other matters as required, for example, research protocols for therapeutic applications of radiation. [Top of Page ] Risks of radiation The likelihood of adverse effects associated with diagnostic medical radiation exposures is generally considered to be low, but any possible effects may not present until many years after the radiation exposure. The two adverse effects most commonly associated with radiation exposure are an increase in the incidence rates of certain cancers and genetic damage. The risk of cancer at low radiation doses (less than 50 mSv) is not proven, but by extrapolation to low doses of those risks obtained from analysis of research participants exposed to high doses, a maximum lifetime risk of cancer can be estimated at 1/18,000 per 1 mSv effective dose (compared with a 25 per cent lifetime natural risk of death from cancer). Evidence for cancer induction by moderate doses of radiation is strongest for children and progressively weaker with advancing age at the time of exposure. The risk of adverse effects can be reduced by choosing research participants for irradiation who are over the age of 50 or beyond childbearing age, where this would not compromise the scientific value of the study. Because of the greater radiation sensitivity of children, participants under 18 years of age should usually be excluded from research with irradiation unless the condition or process being studied is peculiar to people under the age of 18. In this situation, particular care is needed to ensure that the lowest radiation exposure needed to obtain the necessary results is used. The human embryo is especially susceptible to damage from exposure to radiation, particularly between seven and 17 weeks of pregnancy. Therefore, pregnant, or even possibly pregnant, women should be excluded from protocols involving radiation exposure. Research involving radiation could also pose risks to laboratory personnel, nursing staff, and, occasionally, relatives of research participants. This should be avoided by ensuring that all irradiations are supervised by individuals with appropriate radiation training and State radiation worker licensing. Researchers should ensure that potential radiation risks during research are minimised and that participants receive only the amount of radiation necessary to obtain the desired information. Research protocols should be reviewed by experts with appropriate qualifications and training and, as already noted, the number of participants included in the study should not be significantly greater than that required to answer the scientific question. [Top of Page ] Consent Researchers should ensure that potential research participants are clearly informed whenever participation in research studies involves exposure to radiation. Participants must be given sufficient information if they are to make a meaningful decision as to whether or not to participate. One problem with communicating associated risks of radiation to potential research participants is that the risks from small radiation doses are not totally proven or quantifiable, although estimated upper limits of risk are available by extrapolation from higher doses. A further problem is that mathematical expression of these risks may be difficult for most potential participants to comprehend. Several ways of explaining the potential risks associated with exposure to radiation have been suggested, although none are totally satisfactory. One method involves comparing the proposed ‘research effective dose’ with the ‘natural background effective’ dose received each year, or with ‘occupational effective dose’ limits. Another method involves comparing the maximum estimated risk of death from the proposed radiation dose with that of more familiar activities such as air travel or cigarette smoking. The uncertainties surrounding these risk estimates should be made clear to potential participants. It may be appropriate to express the assessment of risk in more than one way, in order to maximise the informed nature of consent. However, it is not recommended that research radiation exposure be compared to exposure from chest X-rays. While this comparison has the advantage of familiarity and acceptability, it suffers from the disadvantage that the actual exposure to radiation from a chest X-ray may vary tenfold. Researchers should ensure that potential research participants have access to expert advice to answer questions they may have about proposed radiation exposure. Points to consider <ul type="disc" style="margin-bottom: 0in"> <li class="MsoNormal"> What effective dose of radiation will the participant receive during the proposed study, and what effective dose of radiation have they received in other research studies over the previous five years? Does this comply with NHMRC requirements? Have the requirements of all relevant State and Territory legislation and the NHMRC Recommendations for Limiting Exposure to Ionising Radiation (1995) been met? </li> <li class="MsoNormal"> Have pregnant women and unnecessarily young participants been excluded? </li> <li class="MsoNormal"> Is the participant a healthy volunteer, or is she or he a patient with a medical condition that may benefit from diagnostic or therapeutic consequences of the radiation exposure? </li> <li class="MsoNormal"> Have statutory notification and approval requirements for ‘healthy volunteer’ radiation exposures been satisfied? </li> <li class="MsoNormal"> Does the scientific merit of the study justify the possible risks of radiation exposure? </li> <li class="MsoNormal"> Does the consent form explain the likely radiation risks in terms that are both accurate and likely to be understood by participants? </li> </ul> Credit:ivythesis.typepad.com

Radiation, Research Involving

Radiation, Research Involving Use of radioactive materials Radioactivity and radiation are natural phenomena to which all hum...

Using Microsatellites and SNPs as Tools in Medical Genetic Diagnostics and Research

Using Microsatellites and SNPs as Tools in Medical Genetic Diagnostics and Research               The field of genetics is considered one of the most interesting fields of science, which has been stirring the curiosity and concern of many scientists and researchers in different expertise. In today’s generation, different applications of genetics can be distinguished and enumerated, including its application in the development of genetic engineering and cloning technology, in teaching and education, in research and studies of different biological phenomena, and in the field of medicine. In this regard, this paper aims to discuss the specific application of genetics in the field of medicine through the emphasis on the use of microsatellites and SNPs in medical genetic diagnostics and research. The subject would be discussed by briefly discussing the use of genetics in the medical field, and by emphasizing on the two important terms. Afterwards, the principle, implications, and actual research examples would be. At the end of the paper, a conclusion would be provided to emphasize on the important points made by the discussion.   Medical Genetics: Brief History and Development             It has been reported that the theories and studies in human genetics have a long history. Observations on the inheritance of physical traits in humans were first accounted by the Greeks, who stressed such observations in their ancient literatures. The 18th and 19th century scientists, who published on the inheritance of numerous diseases, including empirical rules on modes of inheritance, followed further studies and observations of the Greeks. A very important step in the development of human genetics and its application of a Mendelian mode of inheritance in alcaptonuria and other inborn errors of metabolism. It was then followed by Pauling’s elucidation of sickle cell anemia as a molecular disease, the discovery of genetic enzyme defects as the causes of metabolic disease, the determination that there are 46 chromosomes in humans, the development of prenatal diagnosis by amniocentesis, and the large-scale introduction of molecular methods ( 1996). In this regard, human genetics was further related and developed to be related to medical genetics, emphasizing on the use of molecular genetics and DNA technology to practical problems on medical concerns. Such applications include the use of DNA variants as genetic markers in the detection of closely linked genes that are suspected to cause manifestations of diseases and abnormalities. Such has been done through utilizing nucleotide probes that are homologous to the mutations being searched for. Through such applications, treatment of genetic diseases is now being studied, thus, emphasizing on the effective and significant application of genetics in the field of medicine. In this sense, the development of the field of human genetics to medical genetics has become one of the most significant contributions of genetics in the world, being able to provide diagnosis, research, and treatment to many individuals.   Microsatellites and SNPs             DNA polymorphisms are variations in the nucleotide sequence of DNA, which are functionally silent. These are important and widely used genetic markers tagging particular allelic chromosomal regions similar to signposts along roads. Such polymorphic alleles are present in the constitutional DNA of each individual and passed on in the germline to the progeny (2004). In this regard, such polymorphisms are important, most especially in detecting mutations and changes in the pairing of genes. It has been mentioned previously that the detection of gene linkages and mutation can be done using gene markers. This is because gene markers serve to display the sequence of repeats and pairing of genes in a certain organism. Gene markers that serve this purpose include microsatellites and SNPs or single nucleotide polymorphisms. Molecular markers known as microsatellites are small, heritable repeating DNA sequences that vary among and within species of many organisms ( 2004). Microsatellites or STRs (short tandem repeat polymorphisms) are sequences composed of runs of repeat units 2-5bp in length, which are found in the genomes of many eukaryotes (1998). These repeated sequences are ubiquitous in the genomes of a wide range of organisms, and the number of repeats within many of them is highly variable in the population of a particular species. The most common microsatellites in mammals are of the form (dC – dA) (dG – dT) (2002), and in the human genome, there are perhaps 35,000 microsatellite loci, occurring on average every 100,000bp, and with allele lengths of usually between 2 and 50 repeats per locus. The importance of microsatellites lies in their high mutation rates, between 10-2 and 10-5 per gamete, per generation, so that they also vary greatly in copy number between individuals. Such high levels of genetic diversity coupled with neutral evolution, codominance and simple Mendelian inheritance mean that they are also in ideal, and currently extremely popular, set of molecular markers ( 1998). At present, microsatellite polymorphisms or MSPs are now being used for a wide range of applications in genetics, including the construction of genetic linkage maps, linkage mapping of disease genes and quantitative traits, diagnosis of genetic disorders, studies of loss of heterozygosity in tumors, paternity testing, forensic analysis, and selective breeding in the dairy and beef industries (2002). Another molecular marker that indicates polymorphism is the SNP, or the single-nucleotide polymorphisms, which are the most common type of repeated genetic elements. These variations are associated with diversity in the population, individuality, susceptibility to diseases, and individual responses to medicine. This type of variation is particularly noted in the untranslated regions of the genome, that is, in the 5’ and 3’ untranslated regions of the gene, within introns, and in the extragenic regions of DNA, where variations in sequence can occur without as great an impact on function. These polymorphisms are points that normal person in the population and another have. One person has an A-T pair, whereas another has a G-C pair. More than 90% of all human genes contain at least one SNP, and approximately 3 million have been discovered since the human genome sequence was determined (2006). In this regard, both of these polymorphisms can be regarded as important means of detecting genetic sequences and mutations, thus, are both important in medical genetic diagnostics and research.        Using Microsatellites and SNPs: Implications and Research             It has been reported that genetic diseases caused by mutations in one gene are referred to as single gene disorders, while complex or multigene disorders result from a combination of mutations, polymorphisms, and or environmental influences (2004). As emphasized, genetic diseases caused by genetic alterations can be detected through researches and studies using both the microsatellites and SNPs. In this regard, both gene markers are being used as effective and significant gene markers in different researches, most especially in the medical field, in order to help detect and treat genetic mutations and genetic diseases in individuals.             Application of using microsatellites may be of medical importance, as a number of human genetic diseases, such as fragile X syndrome, Huntington’s disease, myotonic dystrophy, and spino-bulbo-muscular dystrophy are associated with a dramatic increase in the copy number of trinucleotide microsatellite repeats. For example, fragile X syndrome, the most common form of inherited (X-linked) mental retardation, and recognized by a fragile or breakable site in the X chromosome, appears to be caused by expansion of a CGG repeat in exon 1 of the FMRI gene. Normally alleles contain between 6 and 50 repeat units whereas clinically affected individuals have more than 200 repeats and frequently more than 1000 ( 1998). The practical laboratory definition of several thousand microsatellite markers for use in pooled genomic screens is an enormous task, but most only be completed once to make the method generally available for association mapping of human disease and trait loci. An automated sequencer or scanner for detection of fluorescently labeled PCR products is the ideal instrument for initial association screening with pooled DNA samples using microsatellites, because it allows a large amount of information to be obtained from each gel ( 2001). On the other hand, SNP markers are clearly the genetic tool of the future, especially for high-throughput, automated research laboratories with resources to purchase sophisticated instruments. SNPs can serve as genetic markers with experiments relying on linkage diequilibrium to detect associations of SNP alleles and phenotypic traits. SNPs also have the possibility of being directly responsible for the phenotype. SNP maps in humans are currently under development, and these maps are leading to an enhanced understanding of human disease (2004). In this regard, SNP technologies are now being used in improving our understanding of the etiology of complex human disease, such as in gene mapping, candidate polymorphism association testing, pharmacogenetics, diagnostics and risk profiling, prediction of response to nonpharmacologic environmental stimuli, and homogeneity testing and epidemiologic study design. While only a few of these areas are currently areas of active research in human genetics, it is most likely that some or all of these areas will become relevant to investigations of the genetic susceptibility to human disease (E2002). However, despite the perceived efficacy and effectiveness of the use of both genetic markers in medical genetic diagnostic and research, comparison of both the use of microsatellites and SNPs are being stressed. Comparison of the two genetic markers emphasizes that SNPs must be used significantly, as abundant and more highly dense SNPs can be obtained in the genome, compared with the use of microsatellites. In addition, using SNPs can also provide at least approximately the same amount of information as the common set of microsatellites (2005). However, SNP markers are somewhat more difficult to type than microsatellites and often have lower rates of heterozygosity in populations and crosses. Nevertheless, they can be designed to virtually any sequence and are less prone to mutation than microsatellites, thus, are particularly useful for association mapping, haplotype, and phylogenetic studies (2007). In its use in medical diagnostics and research, a higher number of SNP loci are required, thus, multiplying the costs in reagents and manpower by 6 to 10 fold. Choosing SNPs over microsatellites also involves considerable investment in equipment that often has higher operating costs than the sequencers used for typing microsatellites. Nowadays, microsatellite libraries can be ordered from companies at a reasonable cost and can be ordered with pre-evaluated primer pairs, thus, significantly cutting down the costs of manpower required for these steps ( 2006). In the end, to reduce labor and cost, the most efficient scheme for completing a pooled screen, including the preliminary marker optimization phase for both microsatellites and SNPs, would be a large collaborative study of several diseases with independent laboratories typing all diseases, and a division of microsatellite markers among laboratories (2001). However, in the process, the use of both genetic markers would be able to make the diagnosis and treatment of genetic or hereditary diseases easier and earlier, thus, significantly allowing the field of genetics to significantly contribute to the preservation of life of individuals. In addition, utilizing such genetic markers in the field of medicine would allow advancement of genetic engineering, which emphasizes genetic testing and gene therapy, in its aim to predict genetic diseases and to override or replace defective genes. Genome scanning using genetic markers can also allow pharmaceutical manufacturers to custom-tailor drugs to a person’s genome, thus, providing more effective treatment (2004). As such, it can be perceived that the use of both microsatellites and SNPs, despite its costs, would allow the significant contribution of genetics in the field of medicine.   Conclusion             From the discussion, it can be understood that the use of both microsatellites and SNPs involves costs and measures, which may somehow hinder its effective research. However, from the significance of its use in genome scanning, the field of medicine would then be developed and improved, most especially in terms of the diagnosis and treatment of individuals, suffering from various genetic disorders. Such findings would be assisted by the use of such genetic markers in the field of research, as certain developments would be useful in developing new drugs and therapies for genetic disorders. In addition, the use of microsatellites and SNPs would augment the field of medical diagnosis, thus, making findings regarding the disease of individuals easier to detect and examine, thus, helping to provide early detection and early treatment.     Credit:ivythesis.typepad.com

Using Microsatellites and SNPs as Tools in Medical Genetic Diagnostics and Research

Using Microsatellites and SNPs as Tools in Medical Genetic Diagnostics and Research The field of genetics is considered o...

The Accuracy of Immunohistochemistry in Duchenne Muscular Dystrophy

The Accuracy of Immunohistochemistry in Duchenne Muscular Dystrophy               Duchene Muscular Dystrophy or DMD is the most severe of the dystrophies, and begins in early childhood, usually before the age of 4, but with a range of 1 to 10 years. Walking is delayed in about half of patients, and when they start walking, they do so clumsily, with frequent falls. Early weakness of the gluteal and hip extensor muscles causes the characteristic waddling gait and compensatory excessive lumbar lordosis. In addition, enlargement of muscles is often present from birth and is more evident in the calves. Proximal weakness of the arms becomes apparent later, but cranial nerves and sphincter functions are consistently spared (2003). DMD results from failure of synthesis of the muscle cytoskeletal protein, dystrophin, whose gene is located on the X chromosome, Xp12. Approximately, 1 in 4,000 male children get affected, being passed on from the mother (2002). It has been reported that women who carry the defective gene passes an abnormal X on to their sons, and since males have an X from their mother and a Y from their father, there is no second X to make up for the defective gene from the carrier mother. In this regard, the sons of the carrier mother each have a 50% chance of having the disease, and the daughters each have a 50% chance of being carriers. Thus, daughters of men with DMD will always be carriers, since they inherit an affected X chromosome from their father (2006). In relation to this disorder is the mutation of the gene for dystrophin. The gene for dystrophin is very large and a common target for mutation. Large deletions or duplications can be detected in the gene for dystrophin in 65% of cases. Demonstration of such mutation provides a useful genetic marker for the disorder, but diagnosis and prognosis require muscle biopsy and immunohistochemistry for the dystrophin protein (2002). In this sense, it can be perceived that in order to effectively detect Duchenne Muscular Dystrophy or DMD, immunohistochemistry must be used. As such, this paper would be discussing the accuracy of immunohistochemistry in DMD through a specific study or experiment.             To be able to attest to the accuracy of immunohistochemistry in DMD, a specific study must be discussed and examined. The particular experiment referred to was written by (2007), and was entitled, “Duchenne and Becker Muscular Dystrophy: A Molecular and Immunohistochemical Approach”. The aim of this experiment is to report the frequency of dystrophin gene deletions in a group of patients with clinical evidences of DMD/BMD. To be able to determine the accuracy of immunohistochemistry, the experiment studied 106 unrelated patients referred for DNA analysis of the dystrophin gene between 1999 and 2005. Such patients had a diagnosis of DMD or BMD based on findings through electromyography and elevated serum creatinine kinase activity. All patients underwent DNA analysis and muscle biopsy. The DNA of the patients was isolated from peripheral blood leukocytes using the standard PCR analysis or phenol/chloroform method. The exons studied include having the numbers 3, 4, 6, 8, 12, 13, 17, 19, 42, 43, 44, 45, 47, 78, 50, 51, 52, 53, 60, and Pm. On the other hand, the muscle biopsy was done in 51 patients, which was freshly frozen and cut on cryostat into 8 micron sections and stained with hematoxylin-eosin, modified Gomori trichrome, oil-red O, PAS, cresyl violet, and Sirius red.             Results of the experiment indicate that at least one deletion in the 20 dystrophin-gene exons were detected in 76 cases. A total of 121 deletions were found in such cases. 82 deletions, corresponding to 68% were detected in exons 42 to 63; 39 deletions, corresponding to 32% were detected in exons 3 to 19, and the most frequent deletions found in the patients were in exons 45, corresponding to 19.05%, exons 19, corresponding to 13.10%, and exons 43, having 11.9%. In addition, the diagnosis of DMD or BMD was confirmed by dystrophin analysis in 39/51 muscular biopsies, 21/39 of which had deletions in the dystrophin gene. One symptomatic carrier showed an absence of the carboxyl region of dystrophin and 35 DMD patients, including one female, showed no reaction for the carboxyl- and amino-terminal and rod domains. Only one BMD patient and two symptomatic female carriers had large gaps or punctuated discontinuous immunostains for dystrophin in the sarcolemma of muscle fibers. 12 of 51 muscle biopsies analyzed showed the presence of other muscle diseases. 2 had severe denervation in the muscle biopsy compatible with spinal muscular atrophy; one had alterations in muscular fibers compatible with congenital myopathy; 2 had sarcoglycan deficiency; and 7 had alterations compatible with muscular dystrophy but had normal immunohistochemistry.             The results of the experiments were said to be compatible with other studies, as the 20 studied exons of the dystrophin gene and detected deletions in 71.7% of the patients were detected in exons 45 and 43. Because the samples of the DNA in this experiment were obtained from the leukocytes of the patients, its results were different to another study, with which samples were obtained from impaired muscle tissues of patients. In this regard, the study may have found out that deletions caused by somatic mosaicism or germ-line cells were not obtained using leukocytes. In relation to immunohistochemistry, it has been emphasized that 30 samples for which DNA deletions were not found were submitted to muscle biopsy and immunohistochemistry for dystrophin, sarcoglycans and dysferlin, thus, showing alterations in muscle fibers. In this regard, immunohistochemistry of muscle biopsy serves to be the gold standard for the effective and efficient diagnosis of DMD/BMD, but is a more invasive procedure and should only be performed in those cases where PCR blood screening does not detect deletions. To spare more patients from muscle biopsy, other techniques to investigate mutations and other methodologies, such as quantitative real-time PCR, should be used, particularly when the patient symptoms, family history, and clinical findings suggest DMD or BMD.             From the results and findings of the experiment, it can be perceived that immunohistochemistry in relation to the detection of BMD or DMD is the most accurate test, thus, allowing precise, effective, and efficient analysis of samples. In this regard, if immunohistochemistry would be used in the detection of the disease, then practical solutions and assistance can be provided to the patient suffering from the disease. Although cure for the disease cannot be provided, temporary assistance for the patient can be given, such as steroids, with the help and support of the family and peers of the patient.      Credit:ivythesis.typepad.com

The Accuracy of Immunohistochemistry in Duchenne Muscular Dystrophy

The Accuracy of Immunohistochemistry in Duchenne Muscular Dystrophy Duchene Muscular Dystrophy or DMD is the most severe ...

Synthesis of Scientific Disciplines in Pursuit of Health the Interactive Biopsychosocial Model

Synthesis of Scientific Disciplines in Pursuit of Health the Interactive Biopsychosocial Model     Abstract Twenty-five years ago, George Engel proposed a challenge to the biomedical model and its limited view of disease as biologically rooted. Building on Engel’s work, we present the Interactive Biopsychosocial Model (IBM). The IBM argues for a reorientation in biomedicine where research, education, and clinical practice: (1) address health in addition to illness; (2) aim to decipher interrelated biophysical, psychocognitive, and social processes in health and disease, rather than seek a single root cause; and (3) take into account the social networks of the individual to achieve, maintain, and maximize health and well-being for individuals, their significant others, and society. Based on an interdisciplinary collaboration of medical and social scientists, this paper demonstrates the application of the IBM to understanding and generating hypotheses about the longitudinal relationship between sexuality and health, and sexuality and chronic illness (diabetes mellitus) at older ages. The model provides a dynamic, dyadic, framework for building scientific hypotheses about the etiologies and consequences of health, well-being, and disease throughout the life course.     The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint far research, a framework for teaching, and a design for action in the real world of health care. —(1977) The time for this larger synthesis of scientific disciplines in pursuit of human health has come. —National Research Council (2001) In 1977, George Engel, professor of psychiatry and medicine at the University of Rochester, proposed integrating psychological and social variables into prevailing models of disease, and created what he called the “biopsychosocial model.” Now, a quarter of a century later, the National Research Council and the Institute of Medicine (IOM) are urging scientists to integrate psychosocial and behavioral processes into attempts to decipher pathways of disease, health, and well-being, and to include biological measures in population-based social science research (2001:  2001 ;2001). This call for integrative approaches is driven in large measure by the increasing prominence of psychosocial issues in clinical practice and education. For example, physicians are often confronted with patients who cannot afford regular checkups or medicines. Older patients experiencing cognitive decline may have difficulty adhering to directions on prescriptions, and patients who have spouses in poor health may be less able to manage their own chronic illness. To promote the cross-disciplinary collaboration necessary for a new approach to the science of health, we need a unified vision of health and disease. In this paper, we examine the theoretical foundations and limitations of disease-oriented models of biomedicine and propose a new model, the Interactive Biopsychosocial Model of health (IBM). Based on Engel’s work, the IBM argues for a reorientation in biomedicine where research, education, and clinical practice: (1) address health in addition to illness; (2) aim to decipher interrelated biophysical, psychocognitive, and social processes in health and disease, rather than seek a single root cause; and (3) take into account the social networks of the individual to achieve, maintain, and maximize health and well-being for individuals, their significant others, and society. The model provides a dynamic framework for building scientific hypotheses about the etiologies and consequences of health, well-being, and disease throughout the life course, and it can be used, in addition, as a teaching tool at the bedside or in the classroom. This work arises from our research in aging and human sexuality, where the greatest scientific and clinical challenge is as often understanding and maintaining health as it is rectifying dysfunction or disease. Additionally, research in sexuality demands a shift in focus from the individual to the dyad or larger social network. The IBM emerged as a framework for scientific investigation about health and life quality over the life course, when it became apparent that we would need to incorporate psychocognitive and psychosocial variables into traditional disease-oriented models. Below we describe this new model and apply it to the relationship between aging and sexuality.   Historical Context In proposing the biopsychosocial model of disease, (1977) issued a “challenge for biomedicine” to reconsider the prevailing biomedical model of disease. The biomedical model, still the dominant framework guiding medical research, education, and clinical care today, focuses on the root cause of disease, where disease is “fully accounted for by deviations from the norm of measurable biological (somatic) variables.” Engel offered, instead, a model designed to “provide a basis for understanding determinants of disease and arriving at rational treatment patterns of health care.” Engel’s groundbreaking work grew out of his clinical psychiatric practice, where he found himself often frustrated by “adherence to a model no longer adequate for the scientific tasks and social responsibilities” of medicine. He aimed, therefore, to change the profession’s approach to the causes of illness and disease, and to widen the framework for the clinical approach to illness, in general, and mental illness in particular. General systems theory was emerging in both the biological and social sciences during the formative years of Engel’s work, and Engel used this theory to lay the groundwork for his biopsychosocial model ( 1967;  1977;  1951; 1968), Engel claimed that “systems theory holds that all levels of organization are linked to each other in a hierarchical relationship so that change in one affects change in the others,” and that this theory treats “sets of related events collectively as systems manifesting functions and properties on the specific level of the whole.” Engel believed that applying systems theory to medicine could reconcile two fundamental tensions implicit in the traditional biomedical model: mind-body dualism, the belief that the mental and the somatic operate independently; and the reductionist-holistic dichotomy, in which complex phenomena are derived from a single physical aberration from the norm rather than from an integrated system where changes interact at various levels. While Engel’s work consciously shifted away from the primacy of biological etiology, he remained focused on the individual as the embodiment of a disease and its consequences. The treatment of disease was still framed in the clinical setting and conceptualized primarily as an interaction between physician and patient. Social variables, only superficially described, became simply additional characteristics of the diseased individual to be considered in the pursuit of the root cause. Although Engel’s work is widely cited in the medical literature (a citation search in the Web of Science Citation Index found 1,419 citations of the Science article as of June 2002), the model remains largely on the margins of biomedicine, particularly as a framework for scientific investigation. Engel’s model has failed to replace the biomedical model for two main reasons: clinicians and scientists continue to emphasize the progression from etiology to disease to the exclusion of health as an outcome; and professional and research institutions are often structurally rooted in the biomedical model. These factors motivate us to reconsider the utility of the biopsychosocial model for defining health. In the following sections, we offer a framework for integrating the social factors that influence health, wellness, illness, and disease into the clinic or the science of medicine.   Defining and Measuring Health Historically, a negative definition of health has prevailed in biomedicine: i.e., health is the absence of disease, dysfunction, or injury, Epidemiologic measures assess population health by rates of morbidity and mortality. Both perspectives rely on normative judgments about the average health of individuals in a given clinical population, community, or society. The primary appeal of these definitions lies in ease of measurement (e.g., measurement of blood pressure, or observation of death certificates), but outcomes in these models are limited to physiological endpoints. Positive outcomes, such as quality of life, well-being, or resilience, typically lie outside these definitions ( 2001). The demographic shift in the age of the U.S. population (2001), combined with medical advances resulting in increased longevity, provides additional impetus for a new, more holistic approach to aging, health, and adult human development. Longer, healthier life in industrialized nations requires a shift in focus from treatment to prevention, from reduction of mortality caused by acute illness to reduction of morbidity due to chronic illness, and from the management of external threats (injury, infection) to the modification of internal threats (negative behaviors such as smoking, poor diet, or sedentary lifestyle). Concepts of successful and productive aging incorporate a positive behavioral orientation and a perspective that encompasses the entire life course ( 2001;  1997). Building on these concepts, the IOM (1998, 2001) proposes “positive health,” defined as “a healthy body; high-quality personal relationships; a sense of purpose in life; self-regarded mastery of life’s tasks; and resilience to stress, trauma, and change.” Health is a “multi-attribute concept” that depends upon a complex network of physical, biological, environmental, economic, social, cultural, and possibly metaphysical (spiritual and moral) factors ( 1998; 2002). The World Health Organization (1958) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” On a population level, the definition of health evolves with social change: “The rising expectations of the past 150 years have led to a shift away from viewing health in terms of survival, through a phase of defining it in terms of freedom from disease, onward to an emphasis on an individual’s ability to perform daily activities, and more recently to an emphasis on positive themes of happiness, social and emotional well-being, and quality of life,” as well as equity and justice in the distribution of health care across societies ( 2000; 1996;  2000;  1987). For the individual, healthiness changes over the life course and involves not only an internal assessment of health and well-being against one’s own prior health and personal expectations, but also an external view of one’s health in reference to others and to societal expectations. Recent debate over the concept of health in the United States has also resulted from health care reform and associated efforts to define coverage and medical necessity or to identify the purpose of health care (Morreim 2000). The debate involves both ethical and philosophical issues and cannot be separated from the pressures of technology or the varying political and economic perspectives of many stakeholders, including, of course, the profession of medicine itself.  (2000), writing for the Hastings Center on the health promotion/disease prevention movement, compares three health “explanatory systems”—medical, behavioral, and socio-environmental—in terms of the compatibility of each with either a libertarian or social justice theory of the common good. This perspective is directly relevant to disputes within the profession of medicine over where responsibility for health lies. Engel recognized this tension 25 years ago in his description of a Rockefeller Foundation seminar on the concept of health, where participants argued that only the organic elements of disease constituted “real” disease and that “the physician should not be saddled with problems that have arisen from the abdication of the theologian and the philosopher” ( 1977).   The Interactive Biopsychosocial Model (IBM) The IBM is based on the IOM concept of health and the following core principles: (1) an orientation toward health rather than illness; (2) analytic capacity for outcomes of health or illness; (3) parity among the three domains of capital (biophysical, psychocognitive, and social) as factors in an individuals health endowment; (4) bi-directional causality and feedback (i.e.. biopsychosocial capital influences the health endowment and the endowment influences access to and use of biopsychosocial resources); (5) primacy of the multi-actor frame (i.e., analysis of individual health or illness embedded in the partner, the family, or other explicitly defined social networks); (6) interdependency of social and life course dynamics; and (7) the potential of capital inputs to act as assets or liabilities. (See Figure 1.) Figure 1 The Interactive Biopsychosocial Model (IBM). Creating and using a dynamic, health-centered model requires an explicit vocabulary to describe and explain the relationships between its core components: the biophysical, psychocognitive, and social dimensions of health. We propose a vocabulary that draws on the socioeconomic concept of capital to specify biophysical, psychocognitive, and social inputs to health. This vocabulary makes it possible to view the components of health as potential assets or liabilities and reinforces the dynamic function of the model, because stocks of capital change over time ( 2001). The application of economic principles to the construction of health models is not new (1964;  1998;  1972),  proposes that “good health” be viewed as a durable capital stock inherited by individuals. The stock increases with investment and depreciates with age; other factors—such as education, gender, or ethnicity (“human capital”)—may positively or negatively affect the rate of health depreciation and efficiency in acquiring good health over time. Biophysical, psychocognitive, and social capital comprise an individual’s health endowment. Biophysical capital includes genetic composition, physiology, physique, sensory function, nourishment, strength, and appearance. Investments in biophysical capital affect an individual’s physical and physiological capacity for health. Psychocognitive capital includes intelligence, emotions, well-being, personality attributes, self-esteem and self-efficacy, coping, and resilience. Investments of this type determine attitudes, interests, and desires related to health. Social capital refers to the networks of dynamic relationships with others (kin, friends, neighbors, physicians) who encourage or sanction certain kinds of behavior, and the social connectedness and social constraints that result. Investment in social capital through monitoring, provision and sharing of information, and solidarity (companionship, love, advocacy) with another determines how much access an individual has to the health endowment ( 1998). We distinguish “social capital” from the notion of “sociocultural context,” a frequently invoked but vague term. In this model, “sociocultural context” is defined as the broader environment of social locations (ethnic, religious, gender, political, or economic class) and summarizes the set of social expectations and norms as well as socially determined conditions, such as differential access to scarce resources, that influence individuals’ health. The health endowment of the individual is inextricably linked to socially relevant others (partner, kin, friend). This mutual dependency for health involves pooling resources, sharing capital, and negotiating joint resources. In our model, this interdependency allows two healthy individuals acting jointly to generate a surplus greater than each would generate alone. The interdependency occurs through repeated small exchanges and specialization of roles within the relationship, and serves to maximize efficiency and efficacy and to perpetuate the interdependency. If individuals have disparate levels of health (one with a large health endowment, the other with a small endowment) or are both in bad health, they may generate a net surplus or a deficit, depending on their relative health, the trajectory of health prior to and within the relationship, and the sociocultural context. In our model, the health endowment can grow and contract over rime, but at any given time, it is finite and quantifiable. Expansion of an individual’s health endowment might occur when an individual begins an intimate partnership. Contraction of the endowment could occur by acquisition of a disease. Individuals may also shift capital resources from one area to another, to stabilize the health endowment and to compensate for specific health challenges. Because the endowment is finite at any given time, investment in biophysical capital, for example through exercise (often a solo activity such as running or biking), could draw resources away from psychocognitive or social capital, although the exchange need not be one-to-one. Alternatively, where physical capital is lowered, social capital may be used to compensate (e.g., a woman with a hip fracture calls on her partner to assist her with dressing and bathing). Alzheimer’s disease may erode psychocognitive capital, but reallocating time or energy to physical capital or social support may lessen the impact of dementia on overall health, Reallocation of resources to maximize health depends on an individual’s connections to significant others and the constraints imposed by these connections. Partnerships characterized by mutually high social capital are the most efficient and show the greatest resilience to health threats. Sociocultural context heavily influences the value and meaning of different kinds of health capital to the individual and affects the extent to which one kind of capital can be substituted for another. Consistent with systems theory, the life course developmental perspective views adult development as an ongoing process in which continuity and change interact in complex ways { 1987; 1992;  1990). Transitions and continuity in the life course constitute adult development and well-being, and the impact of changes and the negotiation of conflicts depend on the social context in which they occur (1993;  1988). We use the life course perspective with a focus on dyadic intimate partnerships to understand mature adult sexuality as adult human development unfolds. In Figure 1, the lower triangle represents the focal individual who connects to a partner represented by the upper triangle. In this case (a study of sexuality and health), an intimate partner is the “other,” but the framework allows for the other to be defined by any primary social connection of interest (the family, a religious congregation, a physician, etc.). This social bond occurs through and within a network of social connections that confer three key bi-directional benefits and constraints: information, monitoring through influence and control, and social solidarity ( 1998). An individual’s social ties may facilitate acquisition of or limit access to pertinent health information. Social ties also exert positive or negative constraints on the individual’s health activities and promote or detract from a person’s sense of social support ( 2002). The triangles link the three forms of capital that comprise the health endowment, and the hourglass shape symbolizes the importance of time in the life course perspective. A central challenge presented by the theoretical framework presented here is the articulation and application of a common metric for quantifying varying types of capital. In application of the model to research questions involving populations, this can be overcome using relative positioning and rank-ordering of individuals along scales of each component type of capital. This approach has been proposed by (2003) in the measurement of socioeconomic status in health research.   Application of the IBM Using the Study of Sexuality and Health at Older Ages We define sexuality as physical capacity, opportunity for partnership and sexual conduct, and attitude. “Sexual capacity” includes the physiologic mechanisms of the sexual response cycle and relaxation, restoration, or physical release from sexual activity. “Sexual conduct” incorporates the activities undertaken to find and maintain a sexual partner. “Sexual attitude” refers to subjective states of desire or interest, beliefs, willingness, preferences, and satisfaction. Capacity, opportunity, and attitude comprise individual-level attributes of sexuality. Intimacy, by contrast, refers to the quality of the dyadic relationship; it describes a quality or condition involving close personal familiarity and feelings of warmth, closeness, and common or shared fate. A strict biomedical hypothesis relating sexuality to health would propose that illness, disability, or reliance on medication(s) predict compromised sexual function. The medical model would say that good health predicts intact sexual function at older ages; that is, people who maintain or improve their health will maintain or improve their sexual function. Likewise, people who become ill, disabled, or dependent on medication, or who experience progressive illness will experience deterioration of sexual function. The emphasis here is on the physical and physiological aspects of disease and sexuality and on the individual. Using the interactive biopsychosocial perspective, however, we posit an interaction between an individual’s own health and the partner’s health as crucial to sexuality, health, and illness. Further, we hypothesize that the expression of sexuality at older ages enhances the beneficial effects and minimizes the detrimental effects of aging on the health of both individuals in the relationship, and also acts as a buffer against chronic illness, physical disability, medication use, cognitive decline, depression, and social isolation at older ages. In socioeconomic terms, sexuality mediates the allocation of resources to the three domains of capital comprising the health endowment. Because health is constructed in relation to another person, the distribution of one individual’s resources for the maintenance of health, which may slow the depreciation of health with age, has a direct impact on the other person’s capital resources and the couple’s joint endowment of health. The relationship between sexuality and health is bi-directional. We further hypothesize that older adults with chronic illness will experience greater compromise of sexual capacity, desire, and opportunity than otherwise similarly healthy counterparts. We expect that older adults whose partners are chronically ill will experience greater sexual dysfunction than others, and that this deficit will negatively affect their overall health. Application of the IBM: The Case of Diabetes Mellitus To illustrate the application of the IBM to a hypothesis about the relationship between older adult sexuality and the expression of chronic disease, we next explore the relationship between sexuality and type 2 diabetes mellitus. Previous research on sexuality in diabetics has focused on the relationship between neurovascular changes and physical sexual function problems such as erectile dysfunction in men (2001; 1998; 1996). Despite a major international attempt to understand the relationship between sexuality and diabetes in women (2002), empirical evidence about the physiologic, psychologic, and social mechanisms is lacking. A strict biomedical hypothesis relating sexuality to diabetes would propose that diabetes predicts compromised sexual function (in particular, erectile dysfunction) at older ages. Over time, age itself will affect sexuality, primarily through physiologic mechanisms. The process and experience of aging may impair sexual function (e.g., vaginal dryness due to estrogen loss in women, or prolonged time to erection in men) or enhance it (more leisure time, equalization of need for foreplay, or deeper awareness of partner’s desires and needs). We hypothesize that people with diabetes who maintain or improve their health will maintain or improve their sexual function. The model also predicts that people with poor glycemic control, disabling disease, or insulin dependence will experience deterioration of sexual function. The IBM allows for an expanded set of hypotheses that incorporate a broader range of physical impairments affecting sexual function among diabetics, such as obesity, frailty, or visual impairments. We can also take into account the partner’s obesity, frailty, or visual impairments as a determinant of the sexual health of individuals with diabetic partners. (See Figure 2.) Figure 2 Effects of diabetes on sexual health. Using the IBM, we hypothesize that diabetics with intact sexuality and strong intimate relationships (intact capacity, interest, and opportunity) exhibit better physical and psychocognitive health, glycemic control, and social functioning at older ages than do similar diabetics with compromised sexuality. We also hypothesize that those with diabetic partners with compromised sexuality will show poorer physical and psychocognitive health and social functioning than those with either healthy partners or with diabetic partners with intact sexuality. Further, if we consider the relationship between sexuality and chronic illness to be bi-directional, we hypothesize that, over time, sexual health protects against or slows the development of Type II diabetes and associated illnesses at older ages by enhancing the beneficial effects and minimizing the detrimental effects of aging on health. In one direction, preservation of sexuality and intimacy lessens the burden of diabetes (e.g., physical activity, feeling of well-being, control, hopefulness, prolongation of independence) and provides biopsychosocial resources for a better quality of life. In the other direction, diabetes diminishes the benefits (e.g more time for enjoying relationships, less inhibition, more physical attunement to partner’s needs) and complicates the detrimental effects (e.g., less intense orgasms, heightened self-consciousness about body image, tougher competition for partners) of aging on sexuality. These hypotheses are supported by pilot work on this subject and form the basis for a national longitudinal study to examine the role of sexuality in mitigating or ameliorating the impact of illness on health at older ages.   Conclusion The 20th century has witnessed astonishing accomplishments in modern medicine. Prevailing models of illness and disease, in combination with technological advances, have transformed our ability to detect and treat disease, and have eradicated many life-shortening illnesses. These successes have significantly extended the human life span and have enhanced the quality of life in industrialized nations. Yet, this unprecedented demographic shift toward longer, healthier life presents an important opportunity to build on traditional, biomedical models of health. The IBM is not meant to detract from the strengths of purely biomedical models, but rather to build on those models and include social and psychological factors affecting diverse biological systems. A strength of the IBM is the explicit incorporation of partners and larger social networks, as well as the social and cultural context in which the individual is embedded. The IBM adds to the repertoire of researchers and practitioners in medicine and health sciences, and gives them a dynamic framework for building scientific or clinical hypotheses about the etiologies and consequences of health, well-being, and disease throughout the life course. The IBM can be applied to a wide range of questions about health outcomes and the processes that produce them, including, for example, adaptation to and course of disease for those with cancer, heart disease, hearing loss, dementia, or other diseases; the effects of disease in spouse, child, or social other on self; the impact of group beliefs, attitudes, and practices on development of disease and maintenance of health. The model also could be used to address health issues in public policy that include developing individual and group interventions to improve health practices, and establishing a public infrastructure that expects, facilitates, and promotes scientific collaboration between disciplines and institutions, both national and international. A model for health that expands beyond the biomedical model is not meant to relegate all responsibility to the medical profession. On the contrary, the ideals of interdisciplinary collaboration in research, education, and the provision of health care is a fundamental inspiration of this model and will determine its success. New opportunities and new challenges require an integrated, interdisciplinary approach, drawing on the impressive advances in biology, medicine, psychology, sociology, economics, and many other disciplines. We will move forward fastest and most efficiently if we link arms, model jointly, and build together.   Credit:ivythesis.typepad.com

Synthesis of Scientific Disciplines in Pursuit of Health the Interactive Biopsychosocial Model

Synthesis of Scientific Disciplines in Pursuit of Health the Interactive Biopsychosocial Model Abstract Twenty-five years ago, Georg...