Basic concepts of Health Planning

Planning is making current decisions in the light of their future effects.

Health planning is a process culminating in decisions regarding the future provisions of health facilities and services to meet health needs of the community.

STUDY GUIDE FOR HEAD AND NECK ANATOMY - MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION ( FREE DOWNLOAD ANATOMY STUDY GUIDES AND MEDICAL MNEMONICS)

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

Ebola Virus [Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) ]

What is Ebola?

Ebola is a virus which causes rare but deadly disease Ebola virus disease (EVD) or Ebola

hemorrhagic fever (EHF) which is a disease of humans and other primates. Symptoms start two days to three weeks after contact with the virus. Symptoms area fever, sore throat, muscle pain, and headaches. Typically nausea, vomiting, and diarrhea follow, along with decreased functioning of the liver and kidneys. Around this time, affected people may begin to bleed both within the body and externally.

Ebola’s natural reservoir is unknown.Non human primates have been the source of human infections but are not thought to be the reservoirs.

Ebola Taxonomy or Scientific Classification

Order: Mononegavirales

  Family: Filoviridae

  Genus: Ebola like viruses

  Species: Ebola 

Subtypes  

Ebola-Zaire, Ebola-Sudan,Ebola-Ivory Coast-disease in humans

Ebola-Reston-disease in nonhuman primates

Filoviridae or “Filoviruses”

•          Most mysterious virus group

•          Pathogenesis poorly understood

•          Ebola

–        Natural history/reservoirs unknown

–        Exist throughout the world

–        Endemic to Africa

–        Filamentous ssRNA^- (antisense) viruses

History

Named after the Ebola River in the Democratic Republic of the Congo (formerly Zaire), near the first epidemics.

Two species were identified in 1976:

• Zaire ebolavirus (ZEBOV)
• Sudan ebolavirus (SEBOV)

Case fatality rates of 83% and 54% respectively.

A third species, Reston ebolavirus (REBOV), was discovered in November 1989 in a group of monkeys (Macaca fascicularis) imported from the Philippines.

Ivory Coast ebolavirus – Only one case. Unlucky scientist.

Outbreaks of EBOLA

Most Recent Incident

April 25 – June 16 2005 total of 12 cases including 9 deaths were reported in Etoumbi and Mbomo in the Cuvette Quest Region

Ebola Pathogenesis

•          Enters Bloodstream

–         Skin, membranes, Open wounds

•          Cell Level

–         Socks with cell membrane

•          Viral RNA

–        Released into cytoplasm

–        Production new viral proteins/ genetic material

•           New viral genomes

–        Rapidly coated in protein

–        Create cores

•          Viral cores

–        Stack up in cell

–        Migrate to the cell surface

–        Produce trans-membrane proteins

–        Push through cell surface

–        Become enveloped by cell membrane

•          ssRNA^- Genome Mutations

–        Capable of rapid mutation

–        Very adaptable to evade host defenses and environmental change

•          Theory

–         Virus evolved to occupy special niches in the wild

Modes of Transmission

There are 3 modes of infection

1. Unsterilized needles
2. Suboptimal Hospital conditions
3. Personal contact

Symptoms and Diagnostic Tests

•          Early symptoms

–        Muscle aches, fever, vomiting

–        Red eyes, skin rash, diarrhea, stomach pain

–        Acute symptoms

–        Bleeding/hemorrhaging from skin, orifices, internal organs

–        Onset of fever.

–        Intense weakness.

–        Muscle Pain.

–        Headache.

–        Soar Throat.

–        Vommitting, Diarrhoea.

–        Impaired Kidnay and liver function

•          Early Diagnosis

•          Very difficult

•          Signs & symptoms very similar to other infections

•          Laboratory Test for the diagnosis of Ebola Virus

•          PCR detection

•          ELISA (enzyme-linked immuno-absorbant) assay

Is there a cure for Ebola?

•          There are no known curative medications for Ebola.

•          However, there have been very recent developments in preventative medications.

•          No Standard Treatment available

•          Patients receive supportive therapy

•          Treating complicating infections

•          Balancing patient’s fluids and electrolytes

•          Maintaining oxygen status and blood pressure

•          No vaccines!

•          Patients are isolated

•          Medical Staff Training

•          Western sanitation practices

•          Intake

•          Care during stay

•          After patient dies

•          Infection-control Measures

•          complete equipment and area sterilization

Vaccines

•          In June, Jones and his colleagues, Dr. Heinz Feldmann of Winnipeg and Dr. Thomas Geisbert at Fort Detrick, Maryland announced that they had successfully vaccinated monkeys against the deadly Ebola virus

•          The Ebola vaccine is based on the 1976 strain of the Zaire species and protects from the 1995, but not the other 2 species that affect humans.

Risk of Bioterrorism?

Airborne transmission of Ebola Zaire has been demonstrated in monkeys in a controlled laboratory experiment

Plum Island…?

Prevention

After Death

Virus contagious in fluids for days

•          Burial use extreme caution

–        Handling and transport

–        Cultural practices/ religious belief

–        Incinerate all waste!!!!

–        Protective clothing

–        Body sealed in body bag and coffin

–        Sanitation of all equipment before and after

–        Risk for exposure special steps need to be taken to protect the family and community from illness.

–        Family only

–        Why open casket not possible

–        Some practices cannot be done

Conclusion

•          Reservoirs in Nature

–        Largely unknown

–        Possibly infected animals (primates?)

•          Transmission

–        Direct contact blood/secretions of infected person

–        Possible airborne (Reston primate facility)

•          Onset of illness abrupt

–        Incubation period:  2 to 21 days

–        Infections are acute and mostly deadly

Latest Morbidity and Mortality Reports

Ebola-Reston Virus Infection Among Quarantined Nonhuman Primates -- Texas, 1996

Report describes death and blood testing of cynomolgus monkey imported from the Philippines held in a private quarantine facility in Texas

•          Outbreak of Ebola Hemorrhagic Fever ---Uganda, August 2000--January 2001

–        Report describes surveillance and control activities related to the EHF outbreak

–        Presents preliminary clinical and epidemiologic findings

Ebola Information Posters

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

Ebola Virus

How to Write a Research Proposal

Framework of the Research Proposal

A research proposal is a written document that includes the following information:

–        Summary of prior literature.
–        Identification of research topic and research questions.
–        Specification of procedure to be followed to answer research questions.

The purpose of your proposal is to sell your idea by showing you have thought it through very carefully and have planned a good research study.

There are three major sections of a research proposal, although the exact headings can vary:
I. Introduction

II. Method
III. Data Analysis

Two examples of Tables of Contents for a research proposal are shown in Table 4.1 (see your textbook).
•         Notice that the headings can vary.
•         When you write a proposal, check with your committee or funding agency to determine if they have a preferred layout of headings.

I. The introduction section of your proposal.

•         The purpose of this section is to introduce your research idea, establish its importance (i.e., you want to “sell” it to your reader), and explain its significance.

•         Flow of the introduction:
–        Start with a general introduction that
•         defines the research topic.
•         demonstrates its importance.
–        Then review the relevant literature.
–        This review should lead directly into a statement of the purpose of the study and your research questions.

II. The method section of your proposal.

•         This provides a written description of the specific actions, plan, or strategy you will take to answer your research questions.
•         It includes information about your proposed
–        Research participants
–        Design
–        Apparatus or instruments, and
–        Procedure.

Participants
The subsection of the method section entitled participants should provide a written description of the individuals who will participate in your research study and how they will be recruited.
Be sure to specify the following

• Their demographic characteristics such as age and gender.
• Inclusion and exclusion criteria you will use.
• Any inducements for participation you plan to use.
• Where they are located.

Design
In this subsection of the method section, entitled “Design, you present your plan or strategy to be used to investigate your research questions.

•         You must include a separate design section if your design is complicated; otherwise you can put in your procedure section.
•         The following is included in the design section:
–        Type of design and design layout of your study (e.g., you might use a pretest-posttest control-group design).
–        Description of all the variables being examined in your study.
–        Description of how your variables are to be combined.
–        Description of the points of measurement and manipulation in the design.

Apparatus and/or Instruments
In this subsection of the method section you describe any apparatus and or instruments you propose to use in your research study. 

• The following information should be included:

–        General description of the apparatus or instruments.
–        Variables measured by instruments.
–        Reliability and validity of instruments.
–        Why the instruments or apparatus are used.
–        Reference indicating where apparatus or instruments can be obtained.

Procedure
In this subsection of the method section of your proposal, you carefully describe how your study will be executed.
•         The following information should be included in the procedure section:
–        A description of the design if it was not previously described.
–        A detailed step-by-step description of how the study will be executed.
The reader should know exactly what you intend to do after reading this description. It should include enough information to tell the reader how to do the study if he or she wanted to replicate it.

III. The data analysis section of your proposal describes exactly how you propose to analyze the data you plan on collecting.

In a quantitative study, you will use some type of statistical analysis. You need to specify those analyses.

In a qualitative study, there is no one or “right” way of analyzing the data. You must explain the approach you propose to use and justify its use. In general, qualitative analysis will involve coding and searching for relationships and patterns in qualitative data.

An abstract is required in completed research studies; it is an optional section in a research proposal. You will need to determine if one is needed in your case.

The elements of the abstract will include the following:

• Concise statement of research hypothesis or research questions.
• Statement of expected number and characteristics of participants.
• Brief summary of procedure or way data will be collected.
• Brief statement of how will analyze results.
• Abstract is optional in proposals.

Sample Research Proposal

Resident:  John Smith, PGY2

Research Mentor:  Jane Doe, MD, Section of General Internal Medicine

Date of Proposal:  February 5, 2009

I.  Title of Proposed Research Project Medical Students as Mediators of Change in Tobacco Use  

II.  Specific Aims

In conducting this study, we will accomplish the following specific aims:

Specific Aim 1.  Compare the effectiveness of the stage specific smoking cessation counseling intervention with the control intervention by evaluating the impact on the following patient outcomes at 1, 3, 6 and 12 months:  a) quit rate, b) stage of change, c) desire to quit, d) motivation to quit, e) confidence in quitting (self-efficacy), and f) nicotine dependence.

Hypothesis 1.  Patients counseled by students initially trained in stage specific smoking cessation counseling will have higher quit rates, improve their stage of change, increase their desire to quit, be more motivated to quit, have higher confidence in quitting, and have less nicotine dependence at 12 months.

Specific Aim 2.  Compare the effectiveness of the stage specific smoking cessation counseling intervention with the control intervention by evaluating the impact on the following processes of care rated by patients at 1, 3, 6 and 12 months:  a) satisfaction with the quality of care in general, and b) satisfaction with the quality of care related to smoking cessation counseling.

Hypothesis 2.  Patients counseled by students initially trained in smoking-specific behavioral counseling will have greater satisfaction with both measures of quality of care at 12 months.

III. Background

Tobacco is the only legally sold product known to cause death in one half of its regular users.(1)  Thus, of the estimated 1.3 billion people in the world who smoke, nearly 650 million will die prematurely as a consequence.(1)  In the United States, approximately 25% of men and 20% of women, or 46 million adults,  smoke.(2)  The financial toll of tobacco use in the U.S. is substantial.  Estimated costs include $75 billon per year in medical expenditures and $80 billion from lost productivity.(3)  The personal health risks of smoking are even more significant with respect to morbidity and mortality.  Although the role of physicians in cessation efforts has been demonstrated, many physicians fail to counsel patients.  The most common reasons cited for lack of counseling include inadequate training and time pressures.  Our intervention will target medical students in the early stages of training.  The proposed intervention will provide a foundation for medical learners in stage specific counseling and will aid physicians in primary practice to help their patients stop smoking.  The rationale for this program is that providing education early and allowing students to use these skills with patients in the community can help: 1) future physicians with confidence in smoking cessation counseling, 2) physicians in the community who may not have adequate time to counsel patients, and 3) patients whose health may be at risk from smoking.

IV. Research Methods

Study Design:  Randomized cross-over trial consisting of two smoking cessation counseling interventions:  1) counseling intervention including patient education, written material and follow-up by students who have been trained in stage specific tobacco cessation techniques, and 2) counseling intervention that includes patient education, written material and follow-up by students who have been trained in non-smoking cessation techniques (exercise counseling).

Setting:  Community practice sites in internal medicine, family medicine and pediatrics throughout Connecticut where medial students attend weekly continuity sessions with physician preceptors.

Study Subjects:  80 first-year medical students and 308-350 patients aged 16 years or older in the students’ community practice sites who are seeing the students’ physician preceptor for any reason and meet criteria of smoking one or more cigarette daily in the previous week.

Randomization:  Students will be randomized by the day they attend their Principles of Clinical Medicine Course and trained in stage specific tobacco cessation counseling or exercise counseling.  After 6 months, students will receive training in the other behavioral counseling technique.

Main Outcome Measures: patients’ quit rate, stage of change, desire to quit, motivation to quit, confidence in quitting (self-efficacy), and nicotine dependence at 1, 3, 6, and 12 months.

Process Measures:  patient satisfaction with the quality of care in general, and satisfaction with the quality of care related to smoking cessation counseling.

Analyses:  patient level analyses of main outcome and process measures comparing patients who received counseling from students trained in smoking cessation counseling and patients who received counseling from students trained in exercise counseling adjusting for potential confounding factors.  We will use logistic regression for dichotomous outcomes and linear regression for continuous outcomes.  We will use generalized estimating equations (GEE) and random effects modeling to allow us to adjust for time-dependent covariates

V. Timeline of Research Project

                                                                                                            Month

Activity                                                                             1     2      3-4       5          6-9     10-12     13-14

Student randomization                                                        X

Train standardized patient                                                          X

Assess student behavioral counseling skills                                                       X

Train student in smoking or exercise counseling                                                X

Assessment of office practice sites                                                                              X

Train medical assistants to recruit patients                                             X

Recruit patients                                                                                    X        X

Patient counseling in-person                                                                                        X         X

Patient counseling by phone                                                                                         X         X

Data collection                                                                                                 X        X

Data analysis                                                                                                               X         X

Prepare publication(s)                                                                                                                    X

Present research at scientific meetings                                                                                             X

VI.  Literature Cited

1.  World Health Organization Website:  WHO tobacco Treaty set to become law, making global public health history.   WHO . 2005. 1-17-2005.

2.  Cigarette smoking among adults--United States, 2001. MMWR Morb Mortal Wkly Rep 2003; 52(40):953-956.

3.  Centers for Disease Control.  Targeting Tobacco Use, the Nation's Leading Cause of Death 2004. CDC. 2005. 1-19-2005.