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3.  WHO relaunches polio campaign 
BMJ : British Medical Journal  2003;327(7413):466.
PMCID: PMC188376  PMID: 12946956
6.  The Successful Relaunch of Scientia Pharmaceutica Continues Achieving Success 
Scientia Pharmaceutica  2011;79(3):695-699.
PMCID: PMC3163360  PMID: 21886912
Study Objective
To identify young women’s pros and cons (decisional balance) to seeking chlamydia (CT) and gonorrhea (NGC) screening.
Prospective, cross sectional study
Community-based reproductive health clinic
192 young women (66% African American; mean age 18.9 years).
Main Outcome Measure(s)
Content analysis of responses obtained during a decisional balance exercise (pros and cons) promoting CT and NGC screening was conducted. Thematic categories were developed through a coding process, and each response was assigned to one thematic category. The frequency of pros and cons responses for each category and the frequency of participants endorsing each category were calculated.
Ten thematic categories in relation to pros and cons of seeking CT and NGC screening were: being healthy; awareness of knowing the body; systemic factors around the clinic visit and testing procedures; benefits and aversions around treatment; partner relationship issues; confidentiality; prevention of long term adverse effects, protection of the body; concern for others; fear of results/aversion to testing; and logistical barriers. The three most often cited pros were awareness, healthy and treatment issues; and the three most often cited cons were logistical barriers (time/transportation), fear/aversion to testing, and systemic issues.
A variety of pros and cons to seeking CT and NGC screening were identified at a community-based clinic. Providers in clinical settings can utilize this information when encouraging patients to seek regular STI screening by elucidating and emphasizing those pros and cons that have the most influence on a young woman’s decision-making to seek screening.
PMCID: PMC2582049  PMID: 18656072
Chlamydia; STI screening; Chlamydia screening; Gonorrhea screening; Decisional Balance; Decisional Balance and STI screening; Transtheoretical model and STI screening
8.  International comparisons of intensive care: informing outcomes and improving standards 
Current opinion in critical care  2012;18(6):700-706.
Purpose of review
Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas where international data provide information relevant to clinical practice and resource allocation.
Recent findings
International comparisons of ICU resources demonstrate that definitions of critical illness and Intensive Care Unit (ICU) beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing.
Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.
PMCID: PMC3551445  PMID: 22954664
Critical Care; Epidemiology; Healthcare Delivery; International Perspectives
9.  Pro/con clinical debate: The use of prone positioning in the management of patients with acute respiratory distress syndrome 
Critical Care  2002;6(1):15-17.
Critical care medicine is a relatively new specialty and as such there is not a great deal of accumulated data to allow clinicians to practice 'evidence-based medicine' in all situations they encounter. When evidence does exist, intensivists may choose not to follow it based on 'gut feelings' or their own interpretation of how the data apply to their patient. It is perhaps not surprising that these latter events occur given that intensivists are often literally fighting for their patient's lives. Prone positioning evokes a large emotional response from many intensivists. Despite accumulating data there appears to be two camps of clinicians: those who strongly believe in the therapy, and those who want more data. The emotion and rationale for the mindset of the two camps is evident in this issue of Critical Care Forum. With compelling arguments on both sides of the fence, it is apparent that this debate is far from over. The authors of this pro/con debate, which is based on a clinical scenario, first describe their position and then respond to their opponent's position.
PMCID: PMC137391  PMID: 11940260
prone position; ventilation; ventilation–perfusion ratio
10.  Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients 
When caring for critically ill children, airway management remains a primary determinant of the eventual outcome. Airway control with endotracheal intubation is frequently necessary. Rapid sequence intubation (RSI) is generally used in emergency airway management to protect the airway from passive regurgitation of gastric contents. Along with a rapid acting neuromuscular blocking agent, sedation is an essential element of RSI. A significant safety concern regarding sedatives is the risk of hypotension and cardiovascular collapse, especially in critically ill patients or those with pre-existing comorbid conditions. Ketamine and etomidate, both of which provide effective sedation with limited effects on hemodynamic function, have become increasingly popular as induction agents for RSI. However, experience and clinical investigations have raised safety concerns associated with both etomidate and ketamine. Using a pro-con debate style, the following manuscript discusses the use of ketamine versus etomidate in RSI.
PMCID: PMC3470433  PMID: 23118665
adrenal suppression; airway management; etomidate; ketamine rapid sequence intubation
11.  Requirements engineering for cross-sectional information chain models 
Despite the wealth of literature on requirements engineering, little is known about engineering very generic, innovative and emerging requirements, such as those for cross-sectional information chains. The IKM health project aims at building information chain reference models for the care of patients with chronic wounds, cancer-related pain and back pain. Our question therefore was how to appropriately capture information and process requirements that are both generally applicable and practically useful. To this end, we started with recommendations from clinical guidelines and put them up for discussion in Delphi surveys and expert interviews. Despite the heterogeneity we encountered in all three methods, it was possible to obtain requirements suitable for building reference models. We evaluated three modelling languages and then chose to write the models in UML (class and activity diagrams). On the basis of the current project results, the pros and cons of our approach are discussed.
PMCID: PMC3799130  PMID: 24199080
The effects of soluble concanavalin A (Con A) or Con A-activated spleen cells on the generation of cytotoxic lymphocytes (CL) in mixed leukocyte cultures (MLC) were examined. Mitogenic concentrations of soluble Con A or small numbers of Con A-activated spleen cells substantially inhibited CL responses. The suppression was partial rather than absolute and was critically dependent upon the concentration and time of addition of soluble Con A or Con A-activated spleen cells to the MLC. Suppressive effects of Con-A activated spleen cells were mediated by T cells since suppressor cell activity was abrogated by treatment of spleen cells with anti-θ serum and complement before or after Con A activation. X irradiation of spleen cells before Con A treatment also abrogated generation of suppressor cell activity. After activation by Con A, however, the function of suppressor cells was radioresistant. Although the precise mechanism(s) of suppression is, as yet, unknown, the precursors of CL must be exposed to Con A-activated cells during the early phases of the immune response for suppression to occur. Kinetic studies revealed that suppression of CL responses was not due to a failure to initiate an immune response, but represented a response which developed initially, but subsequently aborted. The relevance of these observations to the concepts of T-cell-T-cell interaction and regulatory control of immune responses by T cells is discussed.
PMCID: PMC2139593  PMID: 4276949
13.  Gender Specific Differences in the Pros and Cons of Smoking among Current Smokers in Eastern Kentucky: Implications for Future Smoking Cessation Interventions 
This study investigated gender differences in the perceived “pros” and “cons” of smoking using the constructs of decisional balance (DB) and stage of change from the Transtheoretical Model. The population distribution for stage of change among a population-based, cross-sectional survey of 155 current smokers over 40 years was: precontemplation (22.6%), contemplation (41.9%), preparation (35.5%). Results of stepwise regression models indicated significant gender differences in DB were in the preparation stage of change; scores on the DB measure increased 3.94 points (95% CI: 1.94, 5.93) for male smokers. Interventions targeting the “pros” and “cons” of smoking may need to be gender specific.
PMCID: PMC2672317  PMID: 19190354
Transtheoretical model; Decisional-balance; Stage of change; Smoking; Gender
14.  Promoting Advance Care Planning as Health Behavior Change: Development of Scales to Assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change 
To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM.
Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age ≥ 65 years.
Items for each scale/subscale demonstrated high factor loading (> .5) and good to excellent internal consistency (Cronbach α .76–.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks' λ= .555–.809, η2=.068–.178, p ≤ .001 for all models.
Core constructs of the TTM as applied to ACP can be measured with high reliability and validity.
Practice Implications
Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the pros and cons of participation in ACP and promote the use of certain processes of change in order to promote older persons' engagement in ACP.
PMCID: PMC3192927  PMID: 21741194
15.  Concepts and Synonymy in the UMLS Metathesaurus  
This paper advances a detailed exploration of the complex relationships among terms, concepts, and syn­onymy in the UMLS (Unified Medical Language System) Metathesaurus, and proposes the study and under­standing of the Metathesaurus from a model-theoretic perspective. Initial sections provide the background and motivation for such an approach, and a careful informal treatment of these notions is offered as a con­text and basis for the formal analysis. What emerges from this is a set of puzzles and confusions in the Metathesaurus and its literature pertaining to synonymy and its relation to terms and concepts. A model theory for a segment of the Metathesaurus is then constructed, and its adequacy relative to the informal treatment is demonstrated. Finally, it is shown how this approach clarifies and addresses the puzzles educed from the informal discussion, and how the model-theoretic perspective may be employed to eval­uate some fundamental criticisms of the Metathesaurus. For users of the UMLS, two significant results of this analysis are a rigorous clarification of the different senses of synonymy that appear in treatments of the Metathesaurus and an illustration of the dangers in computing inferences involving ambiguous terms.
PMCID: PMC2850250  PMID: 19838995
16.  Usual Care as the Control Group in Clinical Trials of Nonpharmacologic Interventions 
We discuss the pros and cons of including usual care as a control arm in clinical trials of nonpharmacologic interventions. Usual care is a term used to describe the full spectrum of patient care practices in which clinicians have the opportunity (which is not necessarily seized) to individualize care. The decision to use usual care as the control arm should be based on the nature of the research question and the uniformity of usual-care practices. The use of a usual-care arm in a two-arm trial should be considered for trials of investigational drugs or devices, for trials that propose to test interventions that lie well outside usual-care practices, or for trials where the research question per se is to compare a strategy against usual care. Examples of the latter include pragmatic effectiveness trials of clinical pathways or protocolized-care versus usual-care practices. Randomized intervention trials can be safely conducted and monitored using two treatments that lie within the range of usual-care practices if both approaches are considered prudent and good care for the target population.
PMCID: PMC2647648  PMID: 17878473
clinical trials; human experimentation; human subjects protection; control group selection
17.  Patient satisfaction with primary care: an observational study comparing anthroposophic and conventional care 
This study is part of a cross-sectional evaluation of complementary medicine providers in primary care in Switzerland. It compares patient satisfaction with anthroposophic medicine (AM) and conventional medicine (CON).
We collected baseline data on structural characteristics of the physicians and their practices and health status and demographics of the patients. Four weeks later patients assessed their satisfaction with the received treatment (five items, four point rating scale) and evaluated the praxis care (validated 23-item questionnaire, five point rating scale). 1946 adult patients of 71 CON and 32 AM primary care physicians participated.
1. Baseline characteristics: AM patients were more likely female (75.6% vs. 59.0%, p < 0.001) and had higher education (38.6% vs. 24.7%, p < 0.001). They suffered more often from chronic illnesses (52.8% vs. 46.2%, p = 0.015) and cancer (7.4% vs. 1.1%). AM consultations lasted on average 23,3 minutes (CON: 16,8 minutes, p < 0.001).
2. Satisfaction: More AM patients expressed a general treatment satisfaction (56.1% vs. 43.4%, p < 0.001) and saw their expectations completely fulfilled at follow-up (38.7% vs. 32.6%, p < 0.001). AM patients reported significantly fewer adverse side effects (9.3% vs. 15.4%, p = 0.003), and more other positive effects from treatment (31.7% vs. 17.1%, p < 0.001).
Europep: AM patients appreciated that their physicians listened to them (80.0% vs. 67.1%, p < 0.001), spent more time (76.5% vs. 61.7%, p < 0.001), had more interest in their personal situation (74.6% vs. 60.3%, p < 0.001), involved them more in decisions about their medical care (67.8% vs. 58.4%, p = 0.022), and made it easy to tell the physician about their problems (71.6% vs. 62.9%, p = 0.023). AM patients gave significantly better rating as to information and support (in 3 of 4 items p [less than or equal to] 0.044) and for thoroughness (70.4% vs. 56.5%, p < 0.001).
AM patients were significantly more satisfied and rated their physicians as valuable partners in the treatment. This suggests that subject to certain limitations, AM therapy may be beneficial in primary care. To confirm this, more detailed qualitative studies would be necessary.
PMCID: PMC2570361  PMID: 18826582
18.  Factor Structure of Decisional Balance and Temptations Scales for Smoking: Cross-Validation in Urban Female African-American Adolescents 
The transtheoretical model (TTM) is an influential theoretical model in health psychology, particularly in its application to smoking cessation research. Decisional Balance (DB) and Temptations are key constructs within this framework.
This study examines the psychometric properties of the DB and Temptations scales for smoking in a predominantly African American sample of urban adolescent girls.
We used confirmatory factor analysis (CFA) to compare the fit of previously published factor structures in smokers (n=233) and nonsmokers (n=598). External validity was tested by examining stages of change differences in the retained subscales.
Results supported the internal and external validity of the DB scale for smokers and nonsmokers. Notably, previously published 3-factor (Social Pros, Coping Pros, Cons) and 4-factor (Cons split into “Aesthetic Cons” and “Health Cons”) models fit equally well, with Cons subscales correlating highly. For Temptations, a previously published 3-factor (Negative Affect, Social, Weight Control) hierarchical model fit well in nonsmokers. In smokers, previously published subscales were reliably measured but their structural relationship remained unclear. Stage difference tests showed medium to large effect sizes of DB and Temptation subscales in smokers and nonsmokers.
The use of DB was validated for both smokers and nonsmokers in this sample of primarily African American adolescent females, where Cons can be combined or separated into “Aesthetic Cons” and “Health Cons” based on practical utility and preference. For Temptations, more research is needed but large stage differences in Temptations subscales underscore the importance of this concept in smoking acquisition and cessation.
PMCID: PMC3141098  PMID: 21279493
Transtheoretical Model; Decisional Balance; Temptations; Smoking; African Americans; Adolescents
19.  Decisional Balance Regarding Substance Use Among Persons with Schizophrenia 
Community mental health journal  1999;35(4):289-299.
State-of-the-science treatment of substance abuse relies on decisional balance activities (weighing pros and cons of continued substance use) to enhance motivation for change. Few data are available regarding the feasibility of these activities among persons dually diagnosed with schizophrenia and substance use disorder. To address this lacuna in the literature, we completed focus groups with 21 participants, all of whom had a schizophrenia-spectrum diagnosis and lifetime substance abuse or dependence. These key informants discussed the pros and cons of substance use as well as the pros and cons of quitting in response to a structured group interview. Our qualitative data indicate that persons living with schizophrenia can generate rich and diverse decisional balance information. We describe salient themes, contrast complementary perspectives (i.e., the pros of using and cons of quitting), and suggest treatment implications based on these findings.
PMCID: PMC2430516  PMID: 10452697
20.  Perceived pros and cons of smoking and quitting in hard-core smokers: a focus group study 
BMC Public Health  2014;14:175.
In the last decade, so-called hard-core smokers have received increasing interest in research literature. For smokers in general, the study of perceived costs and benefits (or ‘pros and cons’) of smoking and quitting is of particular importance in predicting motivation to quit and actual quitting attempts. Therefore, this study aims to gain insight into the perceived pros and cons of smoking and quitting in hard-core smokers.
We conducted 11 focus group interviews among current hard-core smokers (n = 32) and former hard-core smokers (n = 31) in the Netherlands. Subsequently, each participant listed his or her main pros and cons in a questionnaire. We used a structural procedure to analyse the data obtained from the group interviews and from the questionnaires.
Using the qualitative data of both the questionnaires and the transcripts, the perceived pros and cons of smoking and smoking cessation were grouped into 6 main categories: Finance, Health, Intrapersonal Processes, Social Environment, Physical Environment and Food and Weight.
Although the perceived pros and cons of smoking in hard-core smokers largely mirror the perceived pros and cons of quitting, there are some major differences with respect to weight, social integration, health of children and stress reduction, that should be taken into account in clinical settings and when developing interventions. Based on these findings we propose the ‘Distorted Mirror Hypothesis’.
PMCID: PMC3929905  PMID: 24548463
Hard-core smokers; Pros and cons; Smoking; Quitting; Focus groups; Netherlands
21.  Freeze-fracture cytochemistry: partition of glycophorin in freeze- fractured human erythrocyte membranes 
The Journal of Cell Biology  1982;93(2):463-469.
Thin-section and critical-point-dried fracture-labeled preparations are used to determine the distribution and partition of glycophorin- associated wheat germ agglutinin (WGA) binding sites over protoplasmic and exoplasmic faces of freeze-fractured human erythrocyte membranes. Most wheat germ agglutinin binding sites are found over exoplasmic faces. Label is sparse over the protoplasmic faces. These results contrast with previous observations of the partition of band 3 component where biochemical analysis and fracture-label of concanavalin A (Con A) binding sites show preferential partition of this transmembrane protein with the protoplasmic face. Presence of characteristic proportions of WGA and Con A binding sites over each fracture face is interpreted to indicate the operation of a stochastic process during freeze-fracture. This process appears modulated by the relative expression of each transmembrane protein at either surface as well as by their association to components of the erythrocyte membrane skeleton.
PMCID: PMC2112865  PMID: 7096449
22.  Western impressions of the Hong Kong health care system. 
Western Journal of Medicine  1996;165(1-2):37-42.
Hong Kong, Taiwan, Singapore, and Malaysia are initiating health care reform to meet the changing demands of populations with improved socioeconomic status and access to modern technologies and who are living longer than in previous generations. Hong Kong, in particular, is facing a unique set of circumstances as its people prepare for the transition in 1997 from a British colony to a Special Administrative Region of China. While spending only 4% of its gross domestic product on health care, it has a large and regulated public hospital system for most inpatient medical care and a separate, loosely regulated private health care system for most outpatient medical care. In 1993 the Secretary for Health and Welfare of Hong Kong initiated a year-long process to debate the pros and cons of 5 fundamental programs for health care reform. After a year of open consultation, options were chosen. We describe the Hong Kong health care system, the fundamental changes that have been adopted, and lessons for reformers in the United States.
PMCID: PMC1307539  PMID: 8855683
23.  Non-Alcoholic Fatty Pancreas Disease Pathogenesis: A Role for Developmental Programming and Altered Circadian Rhythms 
PLoS ONE  2014;9(3):e89505.
Emerging evidence suggests that maternal obesity (MO) predisposes offspring to obesity and the recently described non-alcoholic fatty pancreas disease (NAFPD) but involved mechanisms remain unclear. Using a pathophysiologically relevant murine model, we here investigated a role for the biological clock - molecular core circadian genes (CCG) in the generation of NAFPD.
Female C57BL6 mice were fed an obesogenic diet (OD) or standard chow (SC) for 6 weeks, prior to pregnancy and throughout gestation and lactation: resulting offspring were subsequently weaned onto either OD (Ob_Ob and Con_Ob) or standard chow (Ob_Con and Con_Con) for 6 months. Biochemical, pro-inflammatory and pro-fibrogenic markers associated with NAFPD were then evaluated and CCG mRNA expression in the pancreas determined.
Offspring of obese dams weaned on to OD (Ob_Ob) had significantly increased (p≤0.05): bodyweight, pancreatic triglycerides, macrovesicular pancreatic fatty-infiltration, and pancreatic mRNA expression of TNF-α, IL-6, α-SMA, TGF-β and increased collagen compared to offspring of control dams weaned on to control chow (Con_Con). Analyses of CCG expression demonstrated a phase shift in CLOCK (−4.818, p<0.01), REV-ERB-α (−1.4,p<0.05) and Per2 (3.27,p<0.05) in association with decreased amplitude in BMAL-1 (−0.914,p<0.05) and PER2 (1.18,p<0.005) in Ob_Ob compared to Con_Con. 2-way ANOVA revealed significant interaction between MO and post-weaning OD in expression of CLOCK (p<0.005), PER1 (p<0.005) and PER2 (p<0.05) whilst MO alone influenced the observed rhythmic variance in expression of all 5 measured CCG.
Fetal and neonatal exposure to a maternal obesogenic environment interacts with a post-natal hyper-calorific environment to induce offspring NAFPD through mechanisms involving perturbations in CCG expression.
PMCID: PMC3962337  PMID: 24657938
24.  Tipping the Scales: Is Decision Making Related to Readiness to Change in Girls With Eating Disorders? 
Thirty-five adolescent girls with eating disorders completed a new brief measure of motivational stage of change and decisional balance. The study supported Prochaska’s model of behavioral change demonstrating that decision making was consistently related to stage of readiness to change. The girls generated their individual pros and cons of changing and rated the overall strength of pros and cons. Results showed that the strength of the pros of changing was lowest in Precontemplation and highest in Maintenance. The pros of changing primarily reflected their expectation that “taking action” against the eating disorder would improve their body function and decrease their social anxiety. The cons of changing listed reflected concern that changing would negatively affect their body appearance, and that they were fearful of changing.
PMCID: PMC2533829  PMID: 19030153
25.  Changes to perceptions of the pros and cons of genetic susceptibility testing after APOE genotyping for Alzheimer disease risk 
Perceptions about the pros and cons of genetic susceptibility testing are among the best predictors of test utilization. How actual testing changes such perceptions has yet to be examined.
In a clinical trial, first-degree relatives of patients with Alzheimer disease received genetic risk assessments for Alzheimer disease including APOE disclosure. Participants rated 11 possible benefits associated with genetic testing (pros) and 10 risks or limitations (cons) before genetic risk disclosure and again 12 months afterward.
Pros were rated higher than cons at baseline (3.53 vs. 1.83, P < 0.001) and at 12 months after risk disclosure (3.33 vs. 1.88, P < 0.001). Ratings of pros decreased during the 12-month period (3.33 vs. 3.53, P < 0.001). Ratings of cons did not change (1.88 vs. 1.83, P = 0.199) except for a three-item discrimination subscale which increased (2.07 vs. 1.92, P = 0.012). Among specific pros and cons, three items related to prevention and treatment changed the most.
The process of APOE genetic risk assessment for Alzheimer disease sensitizes some to its limitations and the risks of discrimination; however, 1-year after disclosure, test recipients still consider the pros to strongly outweigh the cons.
PMCID: PMC3170997  PMID: 21270636
Alzheimer; pros; cons; benefits; discrimination; genetics; risk; APOE; susceptibility testing; education

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