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Epidemiological evidence regarding the association between carbohydrate intake, glycaemic load (GL) and glycaemic index (GI) and risk of ovarian cancer has been mixed. Little is known about their impact on ovarian cancer risk in African-American women. Associations between carbohydrate quantity and quality and ovarian cancer risk were investigated among 406 cases and 609 controls using data from the African American Cancer Epidemiology Study (AACES). AACES is an ongoing population-based case–control study of ovarian cancer in African-Americans in the USA. Cases were identified through rapid case ascertainment and age- and site-matched controls were identified by random-digit dialling. Dietary information over the year preceding diagnosis or the reference date was obtained using a FFQ. Multivariable logistic regression models were used to estimate odds ratios and 95 % CI adjusted for covariates. The OR comparing the highest quartile of total carbohydrate intake and total sugar intake v. the lowest quartile were 1·57 (95 % CI 1·08, 2·28; Ptrend=0·03) and 1·61 (95 % CI 1·12, 2·30; Ptrend<0·01), respectively. A suggestion of an inverse association was found for fibre intake. Higher GL was positively associated with the risk of ovarian cancer (OR 1·18 for each 10 units/4184 kJ (1000 kcal); 95 % CI 1·04, 1·33). No associations were observed for starch or GI. Our findings suggest that high intake of total sugars and GL are associated with greater risk of ovarian cancer in African-American women.
Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.
In his ABC and Reader of 1807, the German pedagogue Joachim Heinrich Campe warned against teaching children to read before the age of six, arguing that it was better to allow them first to exercise their senses with direct perceptions of nature than to start by conveying knowledge about nature through printed or written signs. Campe worried especially that reading too early could harm a child's ability to perceive things directly: “The learning of signs, and the continual conceiving of signs, weaken and cripple in the young soul the impulse to the clear and lively conceiving of things:, are at best a tedious and wearisome route to the latter; relate to them just as the nonnutritive, merely delaying, merely placating pacifier [Lutschbeutel] does to the full maternal breast.” Campe's concern with the matter of reading coincides here metaphorically with his promotion of breastfeeding as editor of the sixteen-volume pedagogical library entitled Universal Revision of Schools and Education (1785–91), where in a contribution entitled “Dietetics of Nursing” the medical doctor and writer Konrad Friedrich Uden develops Rousseau's construction (in Émile) of breast-feeding as a cornerstone of the bourgeois family into a two-hundred-page polemic against wet-nursing, in favor of nursing by mothers themselves. Campe's critique of signs can also be found in Émile: “What is the use of inscribing in [children's] heads a catalogue of signs which represent nothing for them?”
Who was andré Jolles? born in den helder in 1874; raised in amsterdam; in his youth a significant player in the literary Movement of the Nineties (Beweging van Negentig), whose organ was the Dutch cultural weekly De Kroniek; a close friend of Aby M. Warburg's and Johan Huizinga's—Jolles studied art history at Freiburg beginning in 1902 and then taught art history in Berlin, archaeology and cultural history in occupied Ghent during World War I, and Netherlandic and comparative literature at Leipzig from 1919 until shortly before his death, in 1946. A man of extraordinary intellectual range—his publications include essays on early Florentine painting, a dissertation on the aesthetics of Vitruvius, a habilitation thesis on Egyptian-Mycenaean ceremonial vessels, literary letters on ancient Greek art, and essays in German and Dutch on folklore, theater, dance, Boccaccio, Dante, Goethe, Zola, Ibsen, Strindberg, and Provençal and Renaissance Italian poetry—he was also an amateur playwright and an outspoken champion of modern trends in dramatic art and stage design. To his friends, he could be something of an intellectual midwife, helping Warburg to formulate what would become a signature notion, the “pathos formula,” and Huizinga to conceive The Waning of the Middle Ages (1919). Jolles's chief work, the one for which he is best known, is Einfache Formen (1930; “Simple Forms”), a collection of lectures he had delivered in German at Leipzig in 1927-28 and revised.
Objectives: In recent years, there has been growth in the use of health technology assessment (HTA) for making decisions about the reimbursement, coverage, or guidance on the use of health technologies. Given this greater emphasis on the use of HTA, it is important to develop standards of good practice and to benchmark the various HTA organizations against these standards.
Methods: This study discusses the conceptual and methodological challenges associated with benchmarking HTA organizations and proposes a series of audit questions based on a previously published set of principles of good practice.
Results and Conclusions: It is concluded that a benchmarking exercise would be feasible and useful, although the question of who should do the benchmarking requires further discussion. Key issues for further research are the alternative methods for weighting the various principles and for generating an overall score, or summary statement of adherence to the principles. Any weighting system, if developed, would need to be explored in different jurisdictions to assess the extent to which the relative importance of the principles is perceived to vary. Finally, the development and precise wording of the audit questions requires further study, with a view to making the questions as unambiguous as possible, and the reproducibility of the assessments as high as possible.
Thank you for the opportunity to respond to the letter by Gibson and Little. The authors raise several points that require a response. First, they claim that we inaccurately characterized the DERP/Washington State Medicaid agency, and did not appreciate that the DERP and the Washington State Medicaid agency have different missions. On the contrary, however, we fully recognized that DERP's mission is to conduct systematic reviews and not to make recommendations, whereas Washington State uses the reviews in making recommendations for their Medicaid enrollees. We specifically noted in the study that “Washington Medicaid is one of fourteen participants in the DERP. DERP researchers conduct health technology assessments for drug classes. Participants in the DERP, such as the Washington Medicaid program, retain local authority for interpreting DERP reports and for decision making regarding which drugs to pay for.” We chose to analyze DERP/Washington State as a single entity for our exercise because we were interested in analyzing the link between the HTA conducted and the decisions that follow them.
Previously, our group—the International Working Group for HTA Advancement—proposed a set of fifteen Key Principles that could be applied to health technology assessment (HTA) programs in different jurisdictions and across a range of organizations and perspectives. In this commentary, we investigate the extent to which these principles are supported and used by fourteen selected HTA organizations worldwide. We find that some principles are broadly supported: examples include being explicit about HTA goals and scope; considering a wide range of evidence and outcomes; and being unbiased and transparent. Other principles receive less widespread support: examples are addressing issues of generalizability and transferability; being transparent on the link between HTA findings and decision-making processes; considering a full societal perspective; and monitoring the implementation of HTA findings. The analysis also suggests a lack of consensus in the field about some principles—for example, considering a societal perspective. Our study highlights differences in the uptake of key principles for HTA and indicates considerable room for improvement for HTA organizations to adopt principles identified to reflect good HTA practices. Most HTA organizations espouse certain general concepts of good practice—for example, assessments should be unbiased and transparent. However, principles that require more intensive follow-up—for example, monitoring the implementation of HTA findings—have received little support and execution.
There is a consensus that sudden infant death syndrome, the leading cause of mortality in the first year of life, is multifactorial. Most of the cases are probably due to respiratory or cardiac disorders. It has been proposed that some cases of sudden infant death might result from ventricular fibrillation triggered by a sudden increase in sympathetic activity affecting the heart with reduced electrical stability. This impairment can be due to an insufficient or delayed development of cardiac vagal innervation, with the resultant lack of its protective effect that has been demonstrated to be present since the third week of life. Clinical studies suggest that some of the sudden infant death victims may have a reduced heart rate variability that could be interpreted as a decreased parasympathetic activity to the heart. On the other hand, a reduced cardiac electrical stability may be provoked by a developmental imbalance in sympathetic innervation such to create a dominance of left-sided nerves. We have demonstrated that an imbalance of this type experimentally induced in puppies increases the susceptibility to ventricular fibrillation and prolongs QT interval. In order to demonstrate a significant relationship between prolonged QT interval and sudden infant death, we performed a large prospective study on 18,832 neonates. QT interval corrected for heart rate (QTc) measured from an electrocardiogram on the fourth day of life, was within the normal limits in nine victims from known causes, while it was exceeding the mean by two standard deviations (>433 msec) in six of 12 sudden infant death victims. If these data are confirmed by a larger multicenter study started in Italy, it will be possible to identify some of the sudden infant death victims by the observation of a prolonged QT interval on the electrocardiogram. In this case a preventive strategy based on a time-limited administration of beta adrenergic blocking agents to the infants at risk, might reduce the incidence of sudden infant death.
Health technology assessment (HTA) is a dynamic, rapidly evolving process, embracing different types of assessments that inform real-world decisions about the value (i.e., benefits, risks, and costs) of new and existing technologies. Historically, most HTA agencies have focused on producing high quality assessment reports that can be used by a range of decision makers. However, increasingly organizations are undertaking or commissioning HTAs to inform a particular resource allocation decision, such as listing a drug on a national or local formulary, defining the range of coverage under insurance plans, or issuing mandatory guidance on the use of health technologies in a particular healthcare system. A set of fifteen principles that can be used in assessing existing or establishing new HTA activities is proposed, providing examples from existing HTA programs. The principal focus is on those HTA activities that are linked to, or include, a particular resource allocation decision. In these HTAs, the consideration of both costs and benefits, in an economic evaluation, is critical. It is also important to consider the link between the HTA and the decision that will follow. The principles are organized into four sections: (i) “Structure” of HTA programs; (ii) “Methods” of HTA; (iii) “Processes for Conduct” of HTA; and (iv) “Use of HTAs in Decision Making.”
Our goal in formulating the proposed principles was to stimulate discussion of HTA program goals and procedures to enhance the rigor, validity, and usefulness of HTA. The thoughtful and constructive comments by David Banta, David Hailey, and Duncan Neuhauser are an excellent beginning to what we hope will be an extended and interactive process. We appreciate the opportunity to respond to some of their comments, suggestions, and critiques.
Why did goethe marry Christiane Vulpius, his companion of eighteen years, on 19 October 1806, five days after Napoleon's victory over Prussia at the battle of Jena-Auerstedt? The act perplexed Weimar gossips at the time, angering some, and Goethe's motives for suddenly marrying then have been much discussed since.
After the wedding, a legend rapidly jelled: that the poet had married Christiane primarily out of gratitude, to thank her for her valiant defense of his person and home from the French soldiery plundering Weimar on the “schreckliche Nacht” of 14 October. One report, by the Jena anatomist J. C. Loder, can stand for several:
Goethe ward allerdings geplündert und ein Paar brutale Kerls drangen mit ihren Degen auf ihn ein und hätten ihn vielleicht umgebracht oder wenigstens verwundet, wenn die Vulpius sich nicht auf ihn geworfen und ihn theils dadurch, theils durch einige silberne Leuchter, die sie sogleich hergab, gerettet hätte. Dafür hat er sie geheyrathet und der Herzog hat nachher seine Einwilligung dazu gegeben, auch haben die Weimarischen Damen … die neue Geheime Räthin in ihre Gesellschaften gebeten und sie dadurch gefirmelt.
This explanation (a dominant one in the literature until about 1950, and still recycled in its more popular strains) appears to have been set into circulation by Goethe himself, who cites gratitude as a catalyst for his decision in a letter of 17 October to Wilhelm Christoph Günther (the court chaplain of the Jakobskirche in Weimar) requesting that Günther officiate at his wedding on the 19th.