Ancillary Activities Research Articles

Understanding the Quality Chasm for Hypertension Control in Diabetes: A Structured Review of "Co-maneuvers" Used in Clinical Trials

Observational studies routinely describe a significant gap between rates of blood pressure control in routine diabetes care compared with those achieved in randomized controlled trials (RCTs). We performed a systematic review of the literature to identify co-maneuvers used in RCTs, defined as ancillary activities or agents administered before, during, or immediately after the main agent under investigation (ie, principal maneuver), but not effectively translated to routine diabetes care. We searched multiple databases for RCTs evaluating the efficacy of treatments for hypertension control in adults with type 2 diabetes mellitus. We considered only phase III human studies of interventions that achieved blood pressure control and scrutinized all elements related to the implementation of the principal maneuver in each candidate study. These elements were then sorted into a taxonomy of co-maneuvers. Nearly all eligible RCTs used highly consistent groups of co-maneuvers. These typically began with (1) the use of consensual and clearly stated blood pressure goals; (2) frequent visits in which blood pressure levels were measured and compared with predefined goals; and, if the goal was not attained, (3) modifications to the treatment based on a detailed action plan that included communication of adverse events. Patient education, feedback to clinicians, and interventions for medication adherence were not commonly used among eligible trials. Clinicians should translate key behavioral co-maneuvers along with clinically proven treatments for hypertension control in diabetes. These co-maneuvers are conceptually similar to collaborative goal setting and action planning interventions used in innovative chronic care programs.

PROCEEDINGS OF THE 2006 MIDYEAR COUNCIL MEETING

The midyear meeting of the Council of the Paleontological Society (PS) was called to order by President David J. Bottjer at 8:05 a.m. on 7 April 2006, in the Cooper Room of the Department of Paleobiology at the Smithsonian Institution. Council members William I. Ausich, Derek E. G. Briggs, Mark E. Patzkowsky, Roger D. K. Thomas, Anne L. Raymond, Jennifer C. McElwain, Ann F. “Nancy” Budd, Robyn J. Burnham, Susan H. Butts, Mark A. Wilson, Michael A. Gibson, Jocelyn A. Sessa, Lisa Amati, Forrest J. Gahn, Elizabeth A. Heise, Lisa E. Park and Colin D. Sumrall were present. President Bottjer welcomed the members of the Council and presented his report. Since its inception, the Society had been organized to hold professional meetings, publish results of paleontological research, and engage in a limited range of ancillary activities. Now, with the advent of electronic publishing, a business model based almost entirely on delivery of scholarly journals in hard copy has a limited future. We are in a period of transition from a mixed model of paper and electronic publication to one that will certainly be largely electronic. PS needs to develop new ways to attract and serve its members, to ensure that paleontology will flourish, and to maintain the base of support necessary to publish its journals in any format. Consequently, two major items were on the agenda for this meeting: development of an entirely new membership/subscription model and launching of a fundraising campaign to provide resources in support of the Society's future initiatives. Discussion with H. Richard Lane, program director at NSF, had prompted President Bottjer to write a proposal requesting $25,000 to support travel by U.S. students to the 2006 International Palaeontological Congress, in Beijing. The grant was awarded, a committee was convened to review proposals, and funds were promised …

Forming a community partnership to enhance education in sustainability

PurposeTo provide an example of how colleges can partner with local EcoVillages to further sustainability curriculum on campus and the educational mission of the EcoVillages, and to strengthen ties with the community.Design/methodology/approachDescribes four structured courses developed for the Environmental Studies Program, including sustainable communities, sustainable land use, sustainable energy and environmental futures. Additionally, independent research opportunities in wind energy, solar photovoltaics, and GIS/GPS developed as part of the curriculum. Describes numerous ancillary activities that have promoted sustainability across campus and the community.FindingsProvides information about how to develop educational partnerships with community groups, foster sustainability education on campus, recruit additional faculty involvement, and influence college operations with respect to sustainability.Practical implicationsA very useful source of information for those involved in building sustainability curriculum and linking it to campus operations and community outreach.Originality/valueThis paper describes a unique partnership between a college and an intentional community that serves as a model for other colleges and universities.

HEALTH CARE WORK INCIDENT TO AMBULATORY ENDOSCOPY A MULTI-CENTER ANALYSIS OF WORK AND COST

Purpose: A large industry has developed around the practice of endoscopy in recent years. Although broad guidelines exist for establishing endoscopy practices, regulations for ambulatory endoscopy vary dramatically among different settings resulting in variable ancillary service requirements and staff resource utilization. Ideally, procedure guidelines and related ancillary work should improve quality or safety at a reasonable cost. We searched the medical literature and could not find previous research as to whether such ancillary work achieves the above objectives. As such, we sought to investigate, characterize, measure, and compare the ancillary work associated with ambulatory endoscopy among various institutions with the ultimate hope of determining whether it improves quality and safety efficiently. Methods: We compared the work incident to endoscopy at five health care institutions in the New York City area, including a municipal hospital, a large academic medical center, two community hospitals, and an unregulated physician's private practice. At each site, we observed staff completing forms required for an endoscopy procedure as a measure of ancillary activities and services and then reviewed completed forms in patient charts to investigate and quantify the documentation requirements. Results: In the regulated facilities, the time commitment by staff to provide ancillary services ranged from about a half hour to as much as two hours, compared to five minutes at a physician's private office. The number of forms and items that required completing was also fewest at the physician's office, fairly consistent among the community hospitals and the academic medical center, and highest at the municipal hospital, with the amount of items to be filled out varying by over 80 fold (see Table).Table: Variation in Ancillary Work by FacilityIn general, we noted two types of problems: redundancy, which was most evident at the municipal hospital, and irrelevancy, which was more widespread and comprised work of questionable value in promoting safety or improving care. Conclusions: The ancillary work of ambulatory endoscopy is highly variable across different settings. We found that much of this work is also of seemingly dubious value.

Commentary on the Carvedilol or Metoprolol European Trial (COMET)

β-Adrenergic blockade is commonly and successfully used to treat chronic heart failure. Until recently, few data were available on which to base selection of a particular β-blocking agent. The Carvedilol or Metoprolol European Trial (COMET) provides evidence that β-blockers are not interchangeable. The trial compared carvedilol, a nonselective β-blocker with α-adrenergic blocking and numerous ancillary activities, with metoprolol tartrate. In comparison to metoprolol tartrate, significant reductions in all-cause mortality and cardiovascular mortality were observed with carvedilol. These data indicate that cardiovascular benefit may be obtained from switching patients from metoprolol tartrate to carvedilol.

Pharmacology of carvedilol

Carvedilol is a third-generation, neurohormonal antagonist with multiple activities. It blocks both β 1- and β 2-adrenergic receptors, enhances vasodilation via α 1-adrenergic blockade, and, at high concentrations, has ion channel–blocking activities. Carvedilol lacks sympathomimetic activity. In addition to these well-known properties, carvedilol has a number of ancillary activities, including antioxidant, anti-inflammatory, and antiapoptotic properties. Together, they contribute to the clinical efficacy of carvedilol in a broad spectrum of patient types and may also confer a range of cardioprotective benefits.

Nonprofit Taxable Activities, Production Complementarities, and Joint Cost Allocations

Nonprofit organizations earn both tax—exempt and taxable revenues. Nonprofits may have a natural aversion to engaging in ancillary activities and, as a result, taxable ventures need to provide higher returns than alternative investments. A nonprofits' ability to exploit production complementarities may increase the return to taxable activities and explain the extent to which it engages in taxable ventures. This paper uses tax return data to test the theory that complementarities encourage taxable activities. Complementarities can lower production costs and make it easier for a nonprofit to allocate joint costs from tax-exempt to taxable activities. I find support for both hypotheses.

A Regional Accreditation Perspective on Contingent Faculty Appointments

AbstractWhen the time that contingent faculty spend grading papers, advising students, and attending department meetings is uncompensated, or when curricular development and academic program review are viewed as ancillary activities, then the vitality and integrity of the teaching‐learning process are compromised.

Online rulemaking: a step toward E-governance

Abstract The adoption of electronic rulemaking by many federal agencies provides an opportunity for a greatly enhanced public role—both in terms of the numbers of people who might participate and the depth of their possible participation. This step towards E-governance poses several challenges for agencies: how they should structure their proceedings, how they can process the comments received and how they can foster and take part in the online communities of interest that will result from this activity. The online tools that may be applied to rulemaking and its ancillary activities—advisory committees, advanced notices of proposed rulemaking and enforcement—can also be used at earlier stages of the legislative process to increase public interest, involvement and commitment. This approach is relevant for all levels of government and for any issue on which public hearings are held or public comment solicited. It can provide an efficient and effective nonadversarial process in which officials and members of the public can mutually define problems and explore alternative solutions.

FDA's role in anesthetic drug development.

FDA's role in anesthetic drug development.

Bangladesh's Shrimp Industry and Sustainable Development: Resource-Use Conflict and the Environment

Shrimp culture plays a central part in the fisheries sub-sector in Bangladesh. Cultivation of shrimps experienced a spectacular boost over a period of a decade. This led to a significant change in the structure and composition of Bangladesh's export trade. Through a network of backward and forward linkages, shrimp culture has created substantial employment on shrimp farms as well as an increase in ancillary activities such as trade/commerce, processing and marketing. However, the employment and export gains have been achieved at considerable costs. The present paper identifies these costs using a blend of primary and secondary data. The process of shrimp cultivation epitomises conflicting resource-use patterns. Extensive shrimp-farming systems require more land than intensive ones. Given the extreme scarcity of arable land in Bangladesh, this threatens Bangladesh's ability to expand and sustain rice supply as well as salt production. Increased salinity and soil acidification as a result of shrimp culture are believed to have led to decreased rice yields. Furthermore, declining shrimp yields due to continuous use of the same land and use of chemicals are impediments to sustainable land-use in the shrimp belt with potentially serious implications on the sustainability of rural communities and their livelihoods. The adverse effects of shrimp culture on capture fisheries must also be taken into account.

Coming out of their homesteads?

Bangladesh has experienced a rapid expansion of shrimp farming in the coastal regions in recent years. The increase in both area and production has been influenced by the financial profit motive of rural farmers coupled with high international demands for shrimps and ecological congeniality for shrimp aquaculture. In the past the traditional farming systems in the coastal belts of Bangladesh centred around rice crop. In contrast, the introduction of shrimp aquaculture on a larger/commercial scale has developed shrimp‐based farming systems. Shrimp farming itself is less labour‐intensive than rice cultivation, especially when extensive methods of shrimp culture are practised. Hence, it has reduced on‐farm employment opportunities for rural landless. Nevertheless, shrimp production requires a substantial volume of labour in off‐farm ancillary activities, namely shrimp fry collection, shrimp feed collection, and shrimp processing and packaging for export. Most of this off‐farm work is performed primarily by rural women. This process has engendered a major shift in rural employment and occupational structure in the shrimp belt. Shrimp production has enabled rural women to earn more cash income and to become more active income‐earning members in rural households. While they used to contribute to their share of agricultural work in the homestead before the shrimp cultivation was introduced, now they work mostly outside their homes. This has forced them to stay outside of their homes for longer hours, which limits their time for household duties, more specifically looking after children. All these factors together have implications for the socio‐economic changes in the rural society. The findings that emerge indicate that a range of factors including rural power structure, centre‐periphery issue, rural‐urban migration determine the pattern and extent of employment. It is unclear whether greater employment opportunities for rural women have empowered them or have helped extricate them from various forms of discrimination and exploitation.

Curious learning, cultural bias, and the learning curve

Today's interactive installations are characterized by simplistic feedback mechanisms, limited underlying databases of content, and very little autonomous intelligence. Yet even these rudimentary systems provide great opportunities for curious learning, surprise, and serendipitous discovery. They also serve as a social nexus. The interpersonal, back-channel communications and ancillary activities of the audience, which currently remain largely unsensed and unprocessed, can be just as important as the primary authored experience. The key to accessing and communicating larger perceptions in the digital age may well lie in the collective social activities that occur within the context of shared narratives. The exchanges and experiences of group exploration and discovery, communal curious learning promises rewards far beyond the mere enjoyment of story and the instant gratifications of an individual's remote control.

Implementing Lean Production in an Old Industrial Space: Restructuring at Corner Brook, Newfoundland, 1984–1994

Kruger Incorporated purchased the aging pulp and paper mill in Corner Brook in 1984, armed with a federal-provincial modernization agreement and a pattern-breaking contract with the mill unions. It is argued that changes made in the decade since then correspond most closely with a form of lean production. Six elements of lean production are found at Corner Brook: tighter coordination of production and automation; a continued concentration on core activities; the farming out of ancillary activities; shrinking and segmentation of the workforce; environmental compliance, increasing technical efficiency; and the co-opting of the workforce into the mission of the firm.

Lessons from Managed Care

The infiltration of the health-care environment by health maintenance organizations has been promoted, in part, by instilling fear in physicians about their patient base and creating an illusion of free choice for patients. Within capitation arrangements, specialists are often underpaid for management of complex cases and uncompensated for investment of long hours in ancillary activities. Clinical endocrinologists have been expected to develop algorithms for conditions such as diabetic ketoacidosis, yet application of such guidelines by other clinicians may yield suboptimal results. The transformation of medicine to a business and the focus of insurance administrators on profit rather than high-quality care currently tend to eliminate specialists. Studies that show that high-quality specialty care improves outcomes clinically (and therefore financially) should curb this trend. Nevertheless, a new paradigm for medical care is evolving. Because capitation will not be the only model, clinical endocrinologists should not allow themselves to be exploited in such an arrangement.

Planning Service Capacity When Demand Is Sensitive to Delay

This paper presents a model designed to help determine the number of clerks or servers in a retail queuing situation. The model demonstrates a realistic treatment of the effect of waiting time on customer demand and revenues by treating the average waiting time as a form of price. Thus, the demand rate and service level are interrelated. The number of servers is obtained by balancing the cost of additional servers against the revenues and profits arising from greater demand. An example is shown, using data obtained from a supermarket, to demonstrate the insight gained from applying the model. Some extensions and research possibilities are considered, including a treatment of ancillary activities. An appendix examines a continuous version of the model which provides additional insight into the character of the model.

Commitment to a World Without Cancer

The author is a layperson, health educator, and political oncologist who is, in addition to her work at the cancer center at UCLA, a long-time volunteer with the American Cancer Society. She has served the National Cancer Institute as a member of the National Cancer Advisory Board and is currently a member of its Board of Scientific Counselors, Division of Cancer Control. In these various roles she was part of the lay leadership that influenced and cooperated with the Nixon administration in its efforts to pass the National Cancer Act of 1971. She has participated continually in the implementation of the National Cancer Program and Act since 1971. This essay reviews the history of our nation's support of cancer research, commencing with the founding of the American Cancer Society. It considers the factors that led to the passage of the National Cancer Act in 1971. It then comments on the interaction between universities, the National Cancer Institute, and the Cancer Act, which has produced the "cancer business" that has come of age since the Cancer Act was passed. This commentary does not review the advances made in research and clinical practice as a result of the passage of the National Cancer Act of 1971. Others, better qualified, will do that in this journal and in other publications as well. These views are concerned with the process, the systems, and ancillary activities that have developed as a consequence of the national will to conquer cancer. They are meant to highlight several portions of the whole. The "seeds" of cancer consciousness sown early by the American Cancer Society and those so firmly planted in research and in the creation of a national network of researchers, patient care institutions, and information systems by the National Cancer Institute and the National Cancer Program Plan and Act of 1971 have reaped a harvest of independent programs and even businesses that have given substance to the hopes of those seeking to achieve a world without cancer.

The status of psychosocial research in the rehabilitation of the cancer patient

This article has tried to describe the current status of psychosocial research in the rehabilitation of the cancer patient. It attempted to weave together the author's perspective of how decisions early in the history of sponsored research programs, particularly by the National Cancer Institute, combined with a limited knowledge base led to limited growth of the Rehabilitation Program. Thus, the current status of psychosocial cancer rehabilitation can be reasonably attributed to the decision at the National Cancer Institute to encourage the development of cancer rehabilitation services, rather than to aggressively expand the knowledge base. Although, in retrospect, it is possible to criticize these decisions, in fact, they were legitimate choices among a wide range of options. It was also not possible in this article to discuss many topics in psychosocial cancer rehabilitation, 34 particularly differences in psychosocial adjustment as a function of type of cancer. What the study attempted to do was to confront the impression that cancer rehabilitation, in general, and psychosocial cancer rehabilitation, in particular, are ancillary activities that can receive a secondary level of resource allocation and support. The point was made that determining if psychosocial rehabilitation is possible raises as many basic research questions as does understanding how chemotherapy works or how a malignancy develops. All three areas ask legitimate basic research questions on how the body works and how behavior changes. Today, 10 years after the start of the original Rehabilitation Program, psychosocial cancer rehabilitation is an established field of study and an integral part of most major oncology services. Now, as stated, what is needed is an expansion of its knowledge base. Some of the issues that are deserving of support include studies on cosmesis, to what extent voluntary processes can compensate loss in speech and swallowing functions, functional evaluation following alternative surgical procedures, 47 what is the quality of life following long-term survival of cancer, what are the group dynamics following return of a cancer patient to a work site, and so on. Each of these research questions can be guided by the same model developed for cancer control research by Greenwald and Cullen. 48 Other more general approaches include recognizing and promoting the preventative dimension of cancer rehabilitation 49 and developing the art and practice of psychometric assessment of psychosocial aspects of cancer rehabilitation, just to name two such areas. The American Cancer Society also recently sponsored a meeting to review and set new directions for psychosocial rehabilitation research. 50 What may also be evident from this review is the critical interdependence of science progress and science administration. Paradoxically, much less is known about how to successfully administer a science program then to do science. If the early history of the Rehabilitation Program has any long-term consequence it should be by promoting the study of science administration, in and of itself.

Time allocation of students in basic clinical clerkships in a traditional curriculum.

The objective of this study was to determine the amounts of time spent in various activities by medical students enrolled in basic clinical clerkships. In the fall of 1989, 80 third-year students at the University of North Carolina at Chapel Hill School of Medicine recorded their time allocations in eight categories over 24 hours for three consecutive days. After personal time, the students spent the greatest amount of time in organized educational activities (rounds, conferences, lectures), followed in decreasing order by chartwork, patient contact, examination study, ancillary activities, procedures, and directed study. The students reported an average of 5.8 hours of sleep per night. The students reported that when they were on call, they had significant increases in patient contact, chartwork, and ancillary activities. The authors suggest that third-year students may spend too much of their time in organized educational activities, and may benefit educationally from increased amounts of patient contact and decreased amounts of ancillary activities. These data provide an opportunity for clerkship and curriculum organizers to analyze the efficacy of the basic clinical clerkships.

A reconsideration of fructan biosynthesis in storage roots of Asparagus officinalis L.*

summaryTotal soluble neutral carbohydrate (SNC) from storage roots of seven cultivars of Asparagus officinalis L. was analyzed by HPLC and TLC. Fructan accounted for roughly 90% of the total SNC and, of the fructan fraction, 81–98% was of degree of polymerization of five and larger (DP 5). Smaller oligosaccharides and sucrose represented a correspondingly small proportion of the total SNC. This observation differs from the generally accepted view of Asparagus fructan, which emphasizes the presence of small oligofructan in root tissue.On the basis of chromatographic mobility, neokestose and isokestose were identified as the two components of the trisaccharide fraction. Kestose did not accumulate in any of the cultivars studied.A crude enzyme extract of Asparagus roots was prepared using established methods involving dialysis for 5 d. Microbiological analysis of this preparation revealed heavy bacterial contamination. Oligofructan apparently persisted in this protein preparation despite the long period of dialysis. These observations have consequences for the interpretation of previous reports of in vitro fructosyl transferase data for Asparagus root enzymes. The validity of long‐term dialysis in the study of fructan enzymes is questioned.Crude protein extracts of roots were also desalted using a rapid gel‐exclusion method. When incubated with sucrose under conditions similar to established techniques, both invertase and fructosyl transferase activities were detected in this preparation. The trisaccharide products of the fructosyl transferase reaction were identified on TLC as neokestose, isokestose and kestose; the last did not accumulate in vivo. Oligofructans of DP > 3 were also synthesized by this preparation and the pattern of products revealed by TLC was similar to previous reports. These oligofructan products of enzyme reactions were compared directly with the complete range of fructan structures accumulating in the tissue, using TLC. The enzyme products bore little resemblance to the native fructan pattern. Such enzyme activities are of doubtful physiological relevance and may be the result of artifactual or ancillary activities of other enzymes such as invertase.These findings are discussed with respect to previous studies of Asparagus root carbohydrates and serve as a basis for a critical reassessment of the enzymology of fructan biosynthesis both in this and other plant tissues.