Acceptability of medical digital libraries

Evidenced-based medicine has increased the importance of quick accessibility to reputable, up-to-date information. Web-accessible digital libraries (DLs) on the wards can address the demand for such information. The use and acceptability of these resources has, however, been lower than expected due to a poor understanding of the context of use. To appreciate the social and organizational impacts of ward-accessible DLs for clinicians, results of a study within a large London-based hospital are presented. In-depth interviews and focus groups with 73 clinicians (from pre-registration nurses to surgeons) were conducted, and the data analysed using the grounded theory method. It was found that clinical social structures interact with inadequate training provision (for senior clinicians), technical support and DL usability to produce a knowledge gap between junior and senior staff, resulting in information - and technology - hoarding behaviours. Findings also detail the perceived effectiveness of traditional and digital libraries and the impact of clinician status on information control and access. One important conclusion is that increased DL usability and adequate support and training for senior clinicians would increase perceptions of DLs as support for, rather than replacement of, their clinical expertise

Discrimination against HIV-Infected People and the Spread of HIV: Some Evidence from France

BACKGROUND: Many people living with HIV/AIDS (PLWHA) suffer from stigma and discrimination. There is an ongoing debate, however, about whether stigma, fear and discrimination actually fuel the persisting spread of HIV, or slow it down by reducing contacts between the whole population and high-risk minorities. To contribute to this debate, we analysed the relationship between perceived discrimination and unsafe sex in a large sample of French PLWHAs. METHODOLOGY/PRINCIPAL FINDINGS: In 2003, we conducted a national cross-sectional survey among a random sample of HIV-infected patients. The analysis was restricted to sexually active respondents (N = 2,136). Unsafe sex was defined as sexual intercourse without a condom with a seronegative/unknown serostatus partner during the prior 12 months. Separate analyses were performed for each transmission group (injecting drug use (IDU), homosexual contact, heterosexual contact). Overall, 24% of respondents reported experiences of discrimination in their close social environment (relatives, friends and colleagues) and 18% reported unsafe sex during the previous 12 months. Both prevalences were higher in the IDU group (32% for perceived discrimination, 23% for unsafe sex). In multivariate analyses, experience of discrimination in the close social environment was associated with an increase in unsafe sex for both PLWHAs infected through IDU and heterosexual contact (OR = 1.65 and 1.80 respectively). CONCLUSIONS: Our study clearly confirms a relationship between discrimination and unsafe sex among PLWHAs infected through either IDU or heterosexual contact. This relationship was especially strong in the heterosexual group that has become the main vector of HIV transmission in France, and who is the more likely of sexual mixing with the general population. These results seriously question the hypothesis that HIV-stigma has no effect or could even reduce the infection spread of HIV

Decision tools in health care: focus on the problem, not the solution

BACKGROUND: Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing £5 billion in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint. DISCUSSION: Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem. SUMMARY: We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same

Analysis of chemokine and chemokine receptor expression in squamous cell carcinoma of the head and neck (SCCHN) cell lines

The purpose of this work was to analyze chemokine and chemokine receptor expression in untreated and in irradiated squamous cell carcinoma of the head and neck (SCCHN) tumor cell lines, aiming at the establishment of assays to test for the relevance of chemokine and chemokine receptor expression in the response of SCCHN to radiotherapy and radiochemotherapy. Five low passage and 10 established SCCHN lines, as well as two normal cell lines, were irradiated at 2 Gy or sham-irradiated, and harvested between 1 and 48 h after treatment. For chemokines with CC and CXC structural motifs and their receptors, transcript levels of target and reference genes were quantified relatively by real-time PCR. In addition, CXCL1 and CXCL12 protein expression was analyzed by ELISA. A substantial variation in chemokine and chemokine receptor expression between SCCHN was detected. Practically, all cell lines expressed CCL5 and CCL20, while CCL2 was expressed in normal cells and in some of the tumor cell lines. CXCL1, CXCL2, CXCL3, CXCL10, and CXCL11 were expressed in the vast majority of the cell lines, while the expression of CXCL9 and CXCL12 was restricted to fibroblasts and few tumor cell lines. None of the analyzed cell lines expressed the chemokines CCL3, CCL4, or CCL19. Of the receptors, transcript expression of CCR1, CCR2, CCR3, CCR5, CCR7, CCXR2, and CCXR3 was not detected, and CCR6, CXCR1, and CXCR4 expression was restricted to few tumor cells. Radiation caused up- and down-regulation with respect to chemokine expressions, while for chemokine receptor expressions down-regulations were prevailing. CXCL1 and CXCL12 protein expression corresponded well with the mRNA expression. We conclude that the substantial variation in chemokine and chemokine receptor expression between SCCHN offer opportunities for the establishment of assays to test for the relevance of chemokine and chemokine receptor expression in the response of SCCHN to radiotherapy and radiochemotherapy

Induction and persistence of an immune intestinal imbalance by intestinal y-irradiation in the rat

During radiotherapy for pelvic or abdominal cancer, the intestine is a critical dose-limiting organ. Despite precautions in treatment (planning and delivery), patients develop radiation-induced bowel injury during and for several months after treatment. Radiation enteropathy therefore remains an important obstacle to the radiocurability of abdominal tumors continues to impair patients' quality of life. An inflammatory process associated to immune imbalance has been hypothesized for the development of chronic radiation enteritis. The development of delayed radiation effects involves a continuous process starting immediately at the time of irradiation. The chronic inflammatory reactions are typically characterized by a large infiltrate of immune cells (macrophages, lymphocytes). The balance of cytokines production is crucial to immune response to disease prevention and CD4+ T cells play a prominent role in the disease progression. The persistence of disease susceptibility and resistance depends on the profiles of the cytokines secreted by Th1 and Th2 cells. In the early time, we showed that abdominal single irradiation (10Gy) or fractionated colorectal ?-irradiation (4Gy/fractions, 3 fractions/week and total dose 52Gy) modified the Th1 and Th2 cytokines expression characterized by Th1 cytokines (IFN-gamma/IP10) repression. The Th2 shift occurred via regulation of the level of cytokine-mediators through transcriptional modulation and STAT signaling. During the acute phase, the immune imbalance is associated to an infiltration of macrophages and neutrophiles. This Th1/Th2 imbalance may be attributed to a different radiosensitivity (Th1 more radiosensitive than Th2) and the secretion of a feed-back inhibitor of Th1 polarization potentiating the Th2 profile. In long term (6 months after radiotherapy) the intestinal response may be also driven by the Th2- type responses. The molecular mechanism of this immune imbalance persistence remained unknown. Interestingly, irradiation created an immunosuppressive effect characterized by IL10/STAT3 pathway repression, the pathway known to regulate Th1/Th2 balance. A decrease of the CD4+CD25+FOXP3+ regulatory T cells (Tregs) frequency in the mesenteric lymph nodes may be at the genesis of the IL-10 repression. These results raise the question of whether the Th2 polarization post-irradiation (acute and delayed time) in the intestine involve a highway code of the T cell trafficking induced by a homeostastatic differential chemokines and an alteration of the microvasculature. The assumed loss of tolerance induced by reduced frequency of Treg may be deleterious for Th inactivation and antibacterial responses. These findings suggest the importance to reduce irradiation effects during and after radiotherapy based on immune deviation

Early Inflammatory Changes in Lung Following PuO2 or Pu Nitrate Contamination in the Rat

Increases in cancer incidence and mortality among workers overexposed to alpha-emitting radionuclides, such as plutonium (Pu), have been described with lung tumors of epithelial origin being the most common. However, the question of mechanisms leading to tumor formation following inhalation of radionuclides remains. The main factor controlling tumor incidence seems to be associated with radiation dose distribution, the more homogenous the distribution, the higher the incidence of cancer. In addition, some evidence exists regarding the role of the inflammatory response as a cofactor of tumorigenesis. The present study aims to determine the early inflammatory changes following pulmonary Pu contamination with the insoluble compound, PuO2 or the moderately soluble compound, Pu nitrate. Adult male Sprague-Dawley rats were exposed to PuO2 aerosols using a nose-only inhalation procedure (Initial lung deposit 4.7-43.4 kBq), or received intratracheal administration of Pu nitrate (25 kBq). Fourteen days post contamination, rats were euthanized and bronchoalveolar lavages (BAL) carried out. Activity was measured by liquid scintillation in lungs, femurs and liver. Distribution of activity within lung compartments was also studied. Activation of alveolar macrophages was evaluated by measurement of inflammatory mediators in supernatants collected 24h after plating and intracellular acid phosphatase activity determination, as well as by CD68 immunolabelling on lungs. The higher solubility of Pu nitrate as compared to PuO2 is illustrated by higher activity deposits in skeleton and liver, and lower retention in lungs. However, at this time point, lung distribution does not vary between the 2 compounds, the majority of activity being retained in the cellular fraction of BAL, mainly macrophages. Activation of macrophages is observed in the two groups of contaminated animals, with an enhanced production of TNF-alpha, MCP-1, CINC-1 and MIP-2, and an increased acid phosphatase activity, as compared to sham-contaminated rats. The level of activation was found to be dependant on the initial lung deposit following PuO2 contamination. Our results provide evidence for an early inflammatory response following Pu lung contamination and the role of macrophages whatever the solubility of the Pu compound