Disease-specific Approach Research Articles

Pathways to Care for Patients With Type 2 Diabetes and HIV/AIDS Comorbidities in Soweto, South Africa: An Ethnographic Study.

South Africa is experiencing colliding epidemics of HIV/AIDS and noncommunicable diseases. In response, the National Department of Health has implemented integrated chronic disease management aimed at strengthening primary health care (PHC) facilities to manage chronic illnesses. However, chronic care is still fragmented. This study explored how the health system functions to care for patients with comorbid type 2 diabetes (T2DM) and HIV/AIDS at a tertiary hospital in Soweto, South Africa. We employed ethnographic methods encompassing clinical observations and qualitative interviews with health care providers at the hospital (n=30). Data were transcribed verbatim and thematically analyzed using QSR NVivo 12 software. Health systemic challenges such as the lack of medication, untrained nurses, and a limited number of doctors at PHC clinics necessitated patient referrals to a tertiary hospital. At the hospital, patients with T2DM were managed first at the medical outpatient clinic before they were referred to a specialty clinic. Those with comorbidities attended different clinics at the hospital partly due to the structure of the tertiary hospital that offers specialized care. In addition, little to no collaboration occurred among health care providers due to poor communication, noncentralized patient information, and staff shortage. As a result, patients experienced disjointed care. PHC clinics in Soweto need to be strengthened by training nurses to diagnose and manage patients with T2DM and also by ensuring adequate medical supplies. We recommend that the medical outpatient clinic at a tertiary hospital should also be strengthened to offer integrated and collaborative care to patients with T2DM and other comorbidities. Addressing key systemic challenges such as staff shortages and noncentralized patient information will create a patient-centered as opposed to disease-specific approach to care.

Heterogeneity in Danish lung choirs and their singing leaders: delivery, approach, and experiences: a survey-based study

ObjectivesSinging is considered a beneficial leisure time intervention for people with respiratory diseases, and lung choirs have gained increasing attention. However, there is no available guideline on preferred methodology, and...

Patterns of Multimorbidity in Adults: An Association Rules Analysis Using the Korea Health Panel.

This study aimed to identify the prevalence and patterns of multimorbidity among Korean adults. A descriptive study design was used. Of 11,232 adults aged 18 and older extracted from the 2014 Korean Health Panel Survey, 7118 had one or more chronic conditions. The chronic conditions code uses the Korean Standard Classification of Diseases. Association rule analysis and network analysis were conducted to identify patterns of multimorbidity among 4922 participants with multimorbidity. The prevalence of multimorbidity in the overall population was 34.8%, with a higher prevalence among women (40.8%) than men (28.6%). Hypertension had the highest prevalence in both men and women. In men, diabetes mellitus and hypertension yielded the highest probability of comorbidity (10.04%). In women, polyarthrosis and hypertension yielded the highest probability of comorbidity (12.51%). The results of the network analysis in four groups divided according to gender and age showed different characteristics for each group. Public health practitioners should adopt an integrated approach to manage multimorbidity rather than an individual disease-specific approach, along with different strategies according to age and gender groups.

Adherence and acceptance of a home-based telemonitoring application used by multi-morbid patients aged 65 years and older

Introduction Currently, there are only a small number of comprehensive study results on adherence and acceptance of telemonitoring applications (TMAs) regarding multi-morbid older patients. The ATMoSPHAERE study aimed to develop an information and communication platform for an intersectoral networking of, for example, general practitioners, therapists, social services and the multi-morbid older patient. Methods The study presented was designed as a longitudinal bicentric intervention study which focused on multi-morbid patients aged ≥65 years using home-based telemedical measurement and input devices. The development and testing of this TMA aimed to optimise patients’ health care through intersectoral networking of all treating actors. Quantitative methods of data collection and analysis were used. Results Patients who completed the study were significantly younger than drop-outs and non-participants. The mental health of study patients significantly improved between the beginning and end of TMA use. The main reason for non-participation in the study was the high time expenditure when participating in the study. No perceived (information) benefits for health and insufficient content variety were the main reasons for drop-out. Appropriateness and handling of TMAs must be aligned with the needs of the heterogeneous user group of multi-morbid patients in order to increase acceptance and the added value of TMAs. Telemonitoring hardware should be oriented on functional capabilities of the older target group. Telemonitoring software content requires an individual, disease-specific approach for patients. The TMA should be unobtrusively integrated into usual daily life and be used to an appropriate extent according to the underlying disease in order to avoid stressing patients. With regard to adherence concerning TMAs, it is crucial to provide a contact person who is always available for patients having problems handling TMAs. Health concerns and questions can thus be addressed early, providing a feeling of safety in the care process. Discussion User acceptance of TMAs is an essential indicator and driver for use and for future implementation efforts in health care. In order to achieve maximum user centricity in development processes, patients must be involved as experts, co-designers and future users, considering their needs and perceptions.

Network as a Biomarker: A Novel Network-Based Sparse Bayesian Machine for Pathway-Driven Drug Response Prediction.

With the advances in different biological networks including gene regulation, gene co-expression, protein–protein interaction networks, and advanced approaches for network reconstruction, analysis, and interpretation, it is possible to discover reliable and accurate molecular network-based biomarkers for monitoring cancer treatment. Such efforts will also pave the way toward the realization of biomarker-driven personalized medicine against cancer. Previously, we have reconstructed disease-specific driver signaling networks using multi-omics profiles and cancer signaling pathway data. In this study, we developed a network-based sparse Bayesian machine (NBSBM) approach, using previously derived disease-specific driver signaling networks to predict cancer cell responses to drugs. NBSBM made use of the information encoded in a disease-specific (differentially expressed) network to improve its prediction performance in problems with a reduced amount of training data and a very high-dimensional feature space. Sparsity in NBSBM is favored by a spike and slab prior distribution, which is combined with a Markov random field prior that encodes the network of feature dependencies. Gene features that are connected in the network are assumed to be both relevant and irrelevant to drug responses. We compared the proposed method with network-based support vector machine (NBSVM) approaches and found that the NBSBM approach could achieve much better accuracy than the other two NBSVM methods. The gene modules selected from the disease-specific driver networks for predicting drug sensitivity might be directly involved in drug sensitivity or resistance. This work provides a disease-specific network-based drug sensitivity prediction approach and can uncover the potential mechanisms of the action of drugs by selecting the most predictive sub-networks from the disease-specific network.

Infrastructure-building for Public Health : The World Health Organization and Tuberculosis Control in South Korea, 1945-1963.

This paper examines WHO's involvement in South Korea within the context of the changing organization of public health infrastructure in Korea during the years spanning from the end of the Japanese occupation, through the periods of American military occupation and the Korean War, and to the early years of the Park Chung Hee regime in the early 1960s, in order to demonstrate how tuberculosis came to be addressed as a public health problem. WHO launched several survey missions and relief efforts before and during the Korean War and subsequently became deeply involved in shaping government policy for public health through a number of technical assistance programs, including a program for tuberculosis control in the early 1960s. This paper argues that the principal concern for WHO was to start rebuilding the public health infrastructure beyond simply abolishing the remnants of colonial practices or showcasing the superiority of American practices vis-à-vis those practiced under a Communist rule. WHO consistently sought to address infrastructural problems by strengthening the government's role by linking the central and regional health units, and this was especially visible in its tuberculosis program, where it attempted to take back the responsibilities and functions previously assumed by voluntary organizations like the Korea National Tuberculosis Administration (KNTA). This interest in public health infrastructure was fueled by WHO's discovery of a cost-effective, drug-based, and communityoriented horizontal approach to tuberculosis control, with a hope that these practices would replace the traditional, costly, disease-specific, and seclusion-oriented vertical approach that relied on sanatoria. These policy imperatives were met with the unanticipated regime change from a civilian to a military government in 1961, which created an environment favorable for the expansion of the public health network. Technology and politics were intricately intertwined in the emergence of a new infrastructure for public health in Korea, as this case of tuberculosis control illustrates.

Is the current surge in political and financial attention to One Health solidifying or splintering the movement?

IntroductionThe global health field has witnessed the rise, short-term persistence and fall of several movements. One Health, which addresses links between human, animal and environmental health, is currently experiencing a...

Smoking-Attributable Direct Healthcare Expenditure in Lithuania: A Prevalence-Based Annual Cost Approach.

Introduction: The estimates of the economic burden of smoking provide the basis for a comprehensive assessment of the overall economic impact and evidence for potential public health policy intervention by the government. The aim of this paper is to estimate the smoking-attributable direct healthcare expenditure covered by the Compulsory Health Insurance Fund (CHIF) in Lithuania in 2013. Methods: A prevalence-based and disease-specific annual cost approach was applied to 25 smoking-related diseases or disease categories. Our analysis included only direct government healthcare expenditure (reimbursed by CHIF), including: smoking-attributable outpatient and inpatient care services, medical rehabilitation, reimbursable and publicly procured pharmaceuticals and medical aids, the emergency medical aid (ambulance) service, nursing, and expensive tests and procedures. The smoking-attributable expenditure on the above-mentioned healthcare services was calculated by multiplying the total annual expenditure by the corresponding smoking attributable fractions (SAFs). Results: The total smoking-attributable government expenditure amounted to €37.4 million in 2013. This represented 3% of the total CHIF budget in 2013. Smoking-attributable expenditure on inpatient care and medical rehabilitation services was two times higher for male smokers, than for female smokers. Conclusions: Smoking imposes a significant preventable financial cost within the budget of the Lithuanian healthcare system. A quantitative estimation of smoking related healthcare costs could provide an incentive for the development of smoking cessation services, with additional attention towards male smokers, as well as an important focus on smoking prevention among children and youths.

Induced Pluripotent Stem Cell (iPSC)-Derived Exosomes for Precision Medicine in Heart Failure.

In the United States, heart failure (HF) is the leading cause of hospital admission and a major public health problem.1 Ischemic cardiomyopathy is the primary pathogenesis of advanced HF.1 More than 5 million people experience HF, with an annual incidence of 300 000 patients.1 Despite significant therapeutic advances during the past 3 decades, the 5-year survival remains at a dismal 50%.2 Clinical studies have confirmed that the high morbidity and mortality of HF are because of left ventricular arrhythmias and dilatation.1,2 Patients with a history of acute myocardial infarction and left ventricular dysfunction have a 6-month mortality of >10% of which one third is attributed to sudden cardiac death.3 Although implantable cardioverter defibrillators reduced mortality from left ventricular arrhythmia, patients with acute myocardial infarction do not qualify under the current guideline. An important trigger for ventricular arrhythmias and dilatation is the tissue heterogeneity in the peri-infarct region (PIR), which is independent of the actual infarct size.4–7 An effective targeted therapy to salvage the injured and vulnerable myocardium in the PIR is urgently needed to reduce the high mortality of patients with HF.7,8 Promising discoveries of induced pluripotent stem cell (iPSC) biology may restore the PIR.9,10 The initial theory for the regeneration of the myocardium hypothesized that the transplanted stem cells would differentiate into cardiomyocytes, engraft into the host myocardium, and augment the cardiac function through synchronized electromechanical integration. However, de novo cardiac differentiation of transplanted stem cells was rare and mostly led to teratoma.9,10 Similarly, ex vivo differentiated cardiac stem cells demonstrate transient in vivo engraftment and functional restoration.9,10 Other controversial studies examined the cardiac progenitor cells, a multipotent population of cardiac, vascular, and endothelial cells in the …

Mobile Palliative Care Consultation Service (PCCS): Overview of Hospice and Palliative Care Evaluation (HOPE) Data on In-Patients With End-Stage Cancer, Multiple Sclerosis, and Noncancer, Nonneurological Disease From 4 PCCS Centers in Germany in 2013.

Context:During the last decade, numerous in-patient Palliative Care Consultation Service (PCCS) units were established throughout Germany.Objective:To provide an epidemiological overview on a whole year cohort of palliative patients in terms of demography, complaints, and therapy on admission to PCCS and the impact of PCCS treatment, and identify differences and similarities in different palliative patient subgroups.Methods:Chi-square, analysis of variance (ANOVA), Kruskal-Wallis followed by Games-Howell analysis of HOspice and Palliative care Evaluation (HOPE 2013) data on 4 PCCS centers and in total 919 patients, with solid tumors (237), metastatic cancer (397), leukemia and lymphoma (99), neurological (109, mostly multiple sclerosis [MS]), and noncancer, nonneurological disease (NCNND, 77).Results:A mostly uniform block of 3 cancer subgroups in terms of demographics, admission complaints, and initial pharmacological treatment diverged from the neurologic/MS disease subgroup. The “intermediate,” NCNND subgroup coalesced with the cancer or the neurologic/MS subgroups in part of the demographics, complaint, and drug parameters. Tetraparesis, requirement for nursing, and help with daily living were more, and pain, dyspnea, weakness, appetite loss, and fatigue were less frequent in neurologic patients compared with the cancer subgroups. Neurologic patients also showed more common use of coanalgetics and antidepressives, less opiates and nonopiate analgetics, corticosteroids, and antiemetics and antacids. NCNND patients had a particularly high rate of disorientation (48%) and death during PCCS (39%). In the 3 cancer subgroups, dyspnea, weakness, appetite loss, and anxiolytic use were less frequent in solid tumor patients. Palliative Care Consultation Service treatment was associated with reduction in symptom severity independent of subgroup entity. All listed differences were significant at P < .05 level.Conclusion:Despite divergence in demographics, symptoms, and medication, the data underline general usefulness of PCCS care in all end-stage patients and not only the cancer subgroups. Nevertheless, the strong differences revealed in the current study also underscore the need for a carefully tuned, disease-specific therapeutic approach to these subgroups of palliative patients.

Prevalence-based, disease-specific estimate of the social cost of smoking in Singapore

ObjectiveTo estimate the cost of smoking in Singapore in 2014 from the societal perspective.MethodsA prevalence-based, disease-specific approach was undertaken to estimate the smoking-attributable costs. These include direct and indirect costs...

Economic Burden of Smoking in Iran: A Prevalence-Based Annual Cost Approach

Objectives:The burden of smoking on the health system and society is significant. The current study aimed to estimate the annual direct and indirect costs of smoking in Iran for the year 2014.Methods:A prevalence-based disease-specific approach was used to determine costs associated with the three most common smoking-related diseases: lung cancer (LC), chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD). Data on healthcare utilization were obtained from an original survey, hospital records and questionnaires. The number of deaths was extracted from the global burden diseases study (GBD). The human capital approach was applied to estimate the costs of morbidity and mortality due to smoking-related diseases, classified as direct (hospitalization, outpatients and non-medical costs) and indirect (mortality and morbidity).Results:The total economic cost of the three most common smoking-attributable diseases in Iran was US$1.46 billion in 2014, including US$1.05 billion (71.7%) in indirect and US$0.41 billion (28.3%) in direct costs. Direct costs of the three smoking-related diseases accounted for 1.6% of total healthcare expenditures and total costs were about 0.26% of Iran’s gross domestic product (GDP) in 2014.Conclusions:Our study indicated that smoking places a substantial economic burden on Iranian society. Therefore, sustained smoking cessation interventions and tobacco control policies are required to reduce the magnitude and extent of smoking-attributable costs in Iran.

Uterine Leiomyomas – Minimally Invasive Outcomes on Management and Hospital Stay (MIOMAHS): A Disease Specific Approach

Uterine Leiomyomas – Minimally Invasive Outcomes on Management and Hospital Stay (MIOMAHS): A Disease Specific Approach

Standardizing disease-specific quality of life measures across multiple chronic conditions: development and initial evaluation of the QOL Disease Impact Scale (QDIS®).

BackgroundTo document the development and evaluation of the Quality of life Disease Impact Scale (QDIS®), a measure that standardizes item content and scoring across chronic conditions and provides a summary, norm-based QOL impact score for each disease.MethodsA bank of 49 disease impact items was constructed from previously-used descriptions of health impact to represent ten frequently-measured quality of life (QOL) content areas and operational definitions successfully utilized in generic QOL surveys. In contrast to health in general, all items were administered with attribution to a specific disease (osteoarthritis, rheumatoid arthritis, angina, myocardial infarction, congestive heart failure, chronic kidney disease (CKD), diabetes, asthma, or COPD). Responses from 5418 adults were analyzed as five disease groups: arthritis, cardiovascular, CKD, diabetes, and respiratory. Unidimensionality, item parameter and scale-level invariance, reliability, validity and responsiveness to change during 9-month follow-up were evaluated by disease group and for all groups combined using multi-group confirmatory factor analysis (MGCFA), item response theory (IRT) and analysis of variance methods. QDIS was normed in an independent chronically ill US population sample (N = 4120).ResultsMGCFA confirmed a 1-factor model, justifying a summary score estimated using equal parameters for each item across disease groups. In support of standardized IRT-based scoring, correlations were very high between disease-specific and standardized IRT item slopes (r = 0.88–0.96), thresholds (r = 0.93–0.99) and person-level scores (r ≥ 0.99). Internal consistency, test-retest and person-level IRT reliability were consistently satisfactory across groups. In support of interpreting QDIS as a disease-specific measure, in comparison with generic measures, QDIS consistently discriminated markedly better across disease severity levels, correlated higher with other disease-specific measures in cross-sectional tests, and was more responsive in comparisons of groups with better, same or worse evaluations of disease-specific outcomes at the 9-month follow-up.ConclusionsStandardization of content and scoring across diseases was shown to be justified psychometrically and enabled the first summary measure of disease-specific QOL impact normed in the chronically ill population. This disease-specific approach substantially improves discriminant validity and responsiveness over generic measures and provides a basis for better understanding the relative QOL impact of multiple chronic conditions in research and clinical practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12955-016-0483-x) contains supplementary material, which is available to authorized users.

When People Come First: Critical Studies in Global Health ed. by João Biehl and Adriana Petryna (review)

Reviewed by: When People Come First: Critical Studies in Global Health ed. by João Biehl and Adriana Petryna Peter Redfield João Biehl and Adriana Petryna, eds. When People Come First: Critical Studies in Global Health. Princeton, N.J.: Princeton University Press, 2013. 446 pp. $29.95 (978-0-691-15739-9). These are boom times for global health. Displacing earlier formulations such as tropical medicine and international health, the new moniker now authorizes a range of projects and adorns multiple programs, particularly in the United States. As the editors of this timely volume note, the change is not merely semantic, but [End Page 848] rather reflects a major shift of priorities, resources, and goals. Instead of fostering the growth of national health services in given countries, the global approach emphasizes interconnections between populations, along with increased audit, public-private partnerships, and vertical programs targeting specific problems. A fertile mix of shifting state policies and growing corporate interests—along with humanitarian sentiment and the earnest energy of a legion of researchers and students—have combined to create a veritable new industry. Its initiatives continue to expand worldwide, seeking to measure, educate, vaccinate, test, and treat an array of human targets. When People Come First suggests that the results of all this global activity are not simply salutary. The book is at once a work of careful scholarship and an unabashed appeal for critical reflection derived from ethnographic and historical inquiry. The product of a workshop held at Princeton University in 2010, it offers a set of case studies written by anthropologists and like-minded scholars. As reflected in the title and explained in the introduction, the collective goal is to counterbalance the bureaucratic abstraction of public policy with “peopled accounts”—narratives that emphasize human needs and perspectives, and thus the local realities of this mode of health care. The text divides into three sections of four chapters each, addressing respective themes of evidence, interventions, and markets. The first set of essays situates contemporary trends, in particular increasing emphases on technical solutions, data, law, and moral sentiment. Marcos Cueto traces the reemergence of technical emphasis in malaria control, suggesting a strong resonance between the present moment and 1950s triumphalism. Vincanne Adams examines the expansion of evidence-based medicine and clinical trials onto the global scene, underscoring the human blindness that can accompany statistical insight. Joseph Amon reveals tensions between the collective “right to know” HIV status and the legacy of human rights campaigns related to AIDS activism. Didier Fassin’s contribution explores the moral economy surrounding childhood and analyzes how children emerged as a “consensual object of concern” (p. 128) within public health, exemplified by prevention of mother-to-child transmission, sexual abuse, and orphans. The second part of the book showcases close studies of specific interventions. Tellingly, all come from sub-Saharan Africa, the center gravity of the global health constellation, and two feature HIV/AIDS, its most defining disease. Susan Reynolds Whyte, Michael Whyte, Lotte Meinert, and Jenipher Twebaze map AIDS care in Uganda, focusing particularly on forms of “clientship” related to treatment received from a complex of separate projects rather than a single coordinated source. James Pfeiffer explores related themes in Mozambique, looking at the effects of the major U.S. AIDS initiative (PEPFAR) on that country’s health system. Taken together, the two chapters emphasize a continuing need for administration and basic services, too often sacrificed amid technical innovation. In her contribution, Julie Livingston surveys the looming epidemic of African cancer from the perspective of Botswana’s lone cancer ward. Here ethnography reveals the suffering of underpalliated patients in excruciating detail, clarifying the stakes of both pain recognition and the inadequacy of drug supplies. Amy Moran-Thomas then adds a literal twist to the [End Page 849] worm’s-eye view by examining Guinea worm eradication in Ghana, where the very success of the Carter Center’s campaign against a spectacular parasite highlights the ultimate limits of any vertical, disease-specific approach. The last section of When People Come First turns to economic considerations, and the complex interplay of markets in global health. Stefan Ecks and Ian Harper demonstrate how tuberculosis treatment in India involves a...

Has variation in length of stay in acute hospitals decreased? Analysing trends in the variation in LOS between and within Dutch hospitals.

BackgroundWe aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care.MethodsUsing Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix.ResultsWe found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals’ performances in terms of LOS.ConclusionsThe results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1087-6) contains supplementary material, which is available to authorized users.

Promoting Resilience in Stress Management: A Pilot Study of a Novel Resilience-Promoting Intervention for Adolescents and Young Adults With Serious Illness.

To examine the feasibility and format of the Promoting Resilience in Stress Management (PRISM) intervention among two groups of adolescents and young adults (AYAs) at-risk for poor outcomes: those with Type 1 diabetes (T1D) or cancer. PRISM consists of two long or four short skills-based modules. English-speaking patients 12-25 years old were eligible if they had T1D for >6 months or cancer for >2 weeks. Feasibility was defined as an 80% completion rate and high satisfaction. Ongoing monitoring shaped iterative refinement of disease-specific approach. 12 of 15 patients with T1D (80%) completed the two-session intervention. 3 of 15 patients with cancer declined to complete the two-session version, citing prohibitive length of individual sessions. 12 (80%) completed the four-session version. Patient-reported satisfaction was high across groups. The PRISM intervention is feasible and well-accepted by AYAs with cancer or T1D. Differences in patient populations warrant differences in approach.

Improving outcomes using German Inpatient Quality Indicators in conjunction with peer review procedures

Some hospital comparisons seem to generate confusion because different methods of outcome comparisons lead to different results in hospital rankings. This article questions the concept of overall comparisons of hospitals, which are multiproduct enterprises and may have specialties that provide good results in some areas despite having worse outcomes in others. Therefore, the authors argue for a disease specific view of outcome measurement. The concept of the German Inpatient Quality Indicators is explained. These indicators cover volume, mortality, and other information by a disease specific approach, which includes information for potential patients as well as specific feedback to the physicians responsible for the respective specialty. This article focuses on the feedback to the hospitals and explains how these indicators can be used for improvement in conjunction with a peer review process. The indicators provide information to the hospitals regarding their relative position because German reference values are available for all indicators. Thus, the indicators can serve as a trigger instrument for identifying possible quality problems. Based on these indications, peer review can be used to analyze the treatment processes and to eventually verify weaknesses and define actions for improvement. The first studies indicate that the use of this approach within hospital quality management can largely improve hospital outcomes in hospitals with subpar results compared to the German average.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

To the future: a new direction for Public Health Action.

Public Health Action (PHA) has just completed its third year of publication. It has progressed over this period, and has retained its focus on the priorities that we established for it at the outset. It has attracted a very nice corpus of material focusing on the challenges facing health services and health systems. Many said (or if they didn't say it, they thought it) that our choice of focus was not really ‘science’ in the true sense of the word, and we have proven them wrong. Moreover, coming from a rather narrow focus (as many of us have with a disease-specific approach), we have attracted a wide variety of material with interesting and important topics. This is no mean achievement. The focus of PHA is an area that has received very little attention, despite the fact that high quality health services and health systems are vital to achieving the best outcomes possible for those seeking care. The scientific work presented in PHA over these three years has shown very clearly the wide range of challenges we face in providing the type of care we hope to give (and often thought, erroneously, that we were giving). Creating the new knowledge concerning these challenges and making it available to a wide audience is the first step toward addressing them and toward improving the systems and services with which we work. But it is only the first step. We have seen ideas come forth to challenge us to take responsibility to ensure that action follows words and that this action itself is critically evaluated to ensure that it accomplishes what we think it is meant to do. This we have not yet achieved, and it must be a high priority for the future, both in the work we do and in the articles we present in this Journal. Over the three years of its operations, PHA has managed submitted articles within a very tight time frame with rapid review, and for this we must recognize the work of the many who managed the submissions in a timely manner, undertook the reviews very efficiently and edited the final copy to produce the material that has been publicly presented. Finally, we have managed to produce, and so far sustain, a Journal that is financially stable and not dependent on grants and gifts. And this has been achieved without shifting the priority away from those in greatest need in our world. PHA is unusual in having its primary focus on health solutions for the poor, and it has a fine record of achievement in presenting scientific work primarily from low-income countries. Clearly it is now time for PHA to take on a fresh approach, and a transition to a new Editor-in-Chief is timely. I wish the new person, and all of you together who have committed so much to the Journal, all the very best for the future.