By R. Murak. Molloy College.
That action was a response In the United States pariet 20 mg free shipping, government has traditionally to vigorous opposition to the rule order 20 mg pariet amex. As health insurance became Purported benefits are difficult to estimate accurate- commonplace, the third party payer entered into the ly. The resulting complex of responsibilities, costs are more easily developed and should be avail- relationships and priorities created a mandate for regu- able for any regulation. Regulation of the dental workplace technology, education, and workforce that best is intended to protect the safety of dental practice serve the public interest. There will be Two examples that pose this possibility in the increased demand for continued development of near term are a promulgated but not yet enforced computer-based simulation as a valid method for rule on medical information privacy and a guidance testing clinical skills. Alternatives to professionals must provide translation services to traditional licensure and state-specific licensure will non-English speaking patients. The recent trend in on in-depth clinical competency for the initial com- dental office design has been toward exactly this type petency examination. These are but two examples of why the regu- late more uniform scopes of practice among the latory pendulum will likely continue to swing between state statutes and regulations. A critical under-supply of laboratory techni- cians will occur in the future unless the number of students in this field is increased. The exponential- ly expanding aspects of technology will provide new materials and procedures that will initiate expanded functions for allied personnel. The complexities and interrelations of oral and systemic diseases will continue to evolve and require more extensive examination and diagnosis by a licensed dentist for every dental patient. The liferation of ideas and assumptions, both correct expansion of the predoctoral curriculum has limited and incorrect, must not be allowed to lead to leg- the dental schools ability to teach their students the islative initiatives or regulations without scientific laboratory skills that were traditionally taught in the validation. Dentistry must proactively promote dental labo- to ensure that valid science is the basis for necessary ratory technology as an attractive career choice, as and appropriate regulation. It appears very likely well as increasing the availability of education for den- that one of the greatest issues of today––access to tal laboratory technicians. States should also assure that all regulation is based regulations and overlap of scope may render it diffi- on valid scientific evaluation and solutions. All tal professionals should serve as advocates and resources licensing jurisdictions should meet basic psychome- for developing regulatory policy development. Accreditation of the evaluation process for allied dental personnel through innovative licensure examinations should be investigated. If approaches to education, strengthened standards and when the accreditation process includes out- for continuing education credits, and outcome come assessments of the clinical skills of dental assessments for relicensure and recertification. Increased recruitment efforts will be necessary to Alternatives to live-patient examinations should assure sufficient numbers of dental hygienists, den- continue to be investigated. If successful, the profession will be able to Dental professionals have many opportunities to continue its service to the public unimpeded by meet competency requirements in a positive and ben- unnecessary regulation. The challenge is to find more effective The ability of the profession to influence public and efficient ways to continue to improve the process. Representa- dents more clinical experiences and remediation tives of the practicing dental community must be when needed. Currently, residency programs are involved in the decision-making process as Medicare, available only to the highest-ranking students. This time of great change may ics that serve populations of low socioeconomic sta- introduce operating systems that are not well thought tus. Funding of this additional educational experi- out and certainly are not well tested. Time- The profession must be proactive to ensure that proven, value-driven systems may be destroyed and the policies promoted by advocacy groups are based lives hurt in the process unless there is an appropriate on scientific fact, not anecdotal information. For deliberative process for the institution of regulatory example, increased federal regulation and the geo- change. Regulation will be beneficial if it adds safety graphic mobility of dentists have stimulated the and value to the services provided. References Outcome assessments could be a surrogate for relicensure and/or recertification. Chicago: American Dental ments as an integral part of relicensure or continued Association; 2001. Chicago: of 1999, references to "best practices" criteria are pre- American Dental Association; 1997. Continuing education courses could be strength- Transactions 1976:919; 1977:923; 1989:529; 1992:632. The Chicago: American Dental Association; 1976, Internet creates many possibilities for education as 1977,1989, 1992.
Guilt often results in parents spending more time in seeking excuses for problems than trying to implement solutions purchase pariet 20mg with mastercard. Parents who are convinced that their child has an oral health problem which can be solved tend to react in a positive way order 20mg pariet with amex, both to their dental advisor and the preventive programme itself. It is especially helpful if the preventive strategy can include a system of positive reinforcement for the child (Fig. It must be emphasized that preventive programmes must be carefully planned to include only one major goal at a time. Programmes that involve families have much higher success rates than those which concentrate solely on the patient. Interestingly, families also have a profound influence on levels of dental anxiety among their children. Dentally anxious mothers have children who exhibit negative behaviour at the dentist. The first issue that must be raised is whether dentists have the ethical/moral right to bar parents from sitting in with their children when dental care is being undertaken. Clearly, parents have views and anxiety levels may be raised if parents feel their familial rights are being threatened and a child may be stressed by tension between parents and the operator. These suggestions have merit but they do have a rather authoritarian feel to them, stressing the ordering and voice intonation rather than sympathetic communication. In the end it is a personal decision taken by the dentist in the light of parental concerns and clinical experience. Patients with special needs require a high degree of parental involvement in oral health care, particularly for those children with educational, behavioural, and physical difficulties. For example, toothbrushing is a complex cognitive and motor task which will tax the skills of many handicapped children. A parent will have to be taught how to monitor the efficiency of the plaque removal and intervene when necessary, to ensure the mouth is cleaned adequately. Diet is also important, so clear advice must be offered and reinforcement planned at regular intervals. Clearly, only broad guidelines can be presented on how to maintain an effective relationship with a patient, as all of us are unique individuals with different needs and aspirations. This is especially so in paediatric dentistry where a clinician may have to treat a frightened 3-year-old child at one appointment and an hour and a half later be faced with the problem of offering preventive advice on oral health to a recalcitrant 15 year old. There are, however, common research findings which highlight the key issues that will cause a dentist/ patient consultation to founder or progress satisfactorily. Most people try to find out details about different dental practices from friends and colleagues. While the technical skill of the dentist is of some concern, the most important features people look for are, a gentle friendly manner, explains treatment procedures, and tries to keep any pain to a minimum. As with any health issue the social class background of the respondents influences attitudes and beliefs. For example, parents of high socioeconomic status are more interested in professional competence and gaining information, whereas parents from poorer areas want a dentist to reassure and be friendly to their child. So which dentist parents choose to offer care to their child will depend to some extent on reports about technical skill from family and friends, but the major driving force is well-developed interpersonal skills. The proposed model consists of six stages, and is based on the work of Wanless and Holloway (1994). If parents are present then include them in the conversation, but do not forget that the child should be central to the developing relationship. A greeting can be spoilt by proceeding too quickly to an instruction rather than an invitation. The greeting should be used to put the child and parents at ease before proceeding to the next stage. For children who have been before it is helpful to record useful information such as the names of brothers/sisters, school, pets, and hobbies. By talking generally and taking note of what the child is saying you are offering a degree of control and reducing anxiety. In this stage the aim is to explain what the clinical or preventive objectives are in terms that parents and children will understand. This is a vital part of any visit as it establishes the credibility of the dentist as someone who knows what the ultimate goal for the treatment is, and is prepared to take the time and trouble to discuss it in non-technical language. While not wishing to labour the point, it must be stressed that sensible information cannot be offered to the patient or parents until the clinician has a full history and a treatment plan based on adequate information. This requires a broad view of the patient and should not be totally tooth-centred. It is all too easy to lose the confidence of parents and children if you find yourself making excuses for clinical decisions taken in a hurried and unscientific manner.
The major incentive for the phar- maceutical industry to participate in the development of personalized medicine is the increasing interest and technologies available for developing such medicines discount pariet 20 mg. In future purchase 20mg pariet with mastercard, we will see more competition among the companies in this area as those who do not remain on the forefront will be at a considerable disadvantage in the future healthcare market. Companies such as Hoffmann-La Roche are in a good position to develop such innovative healthcare systems as they have the largest molecular diagnostic facility and already have products where diagnostics and therapeutics are packaged together. Individual technologies and data for the development of person- alized medicine stem mostly from biotechnology companies. Principles of personal- ized medicine play an important role at all stages of the drug development process. Personalized Drug Discovery To start with use of established drugs is being personalized. Assays of drug action typically evaluate biochemical activity; however, accurately matching therapeutic efﬁcacy with biochemical activ- ity is a challenge. High-content cellular assays seek to bridge this gap by capturing broad information about the cellular physiology of drug action. The detailed infor- mation contained in genomic expression data is sufﬁcient to match the physiologi- cal effect of a novel drug at the cellular level with its clinical relevance. This capacity to identify therapeutic efﬁcacy on the basis of gene expression signatures in vitro has potential utility in drug discovery and drug target validation relevant to personalized medicine. Personalized Approach to Clinical Trials It is well recognized that average treatment effects estimated by systematic reviews of clinical trials do not really apply to an individual patient, and might differ in patient subgroups. This can lead to treatment of patients for whom the treatment is not effective, and may be harmful. Positive clinical trial results may mask a lack of meaningful beneﬁt for those at lower risks of illness, e. The authors emphasized that the problem of trials masking the “heterogeneity of Universal Free E-Book Store Role of Pharmaceutical Industry 593 treatment effects” can result in guidelines that promote overtreatment as well as undertreatment, and recommended estimation of treatment effects after stratifying trial participants according to baseline risk. Better stratiﬁcation of persons by dis- ease stage, or baseline risk of relevant outcomes, is more likely to identify those who will beneﬁt and those who will be harmed by an intervention, leading to the development of appropriate diagnostic and treatment thresholds, ultimately reduc- ing overdiagnosis as well as overtreatment (Moynihan et al. Pharmacogenomic approach to clinical trials is discussed in Chapter and other measures to improve clinical trials are discussed in the following sections. Use of Bayesian Approach in Biomarker-Based Clinical Trials Innovative clinical trial designs are needed to address the difﬁculties and issues in the development and validation of biomarker-based personalized therapies. A new clinical trial design that captures the strengths of the frequentist and Bayesian approaches has been proposed to address some of these issues (Lai et al. There are advantages of using likelihood inference and interim analysis to meet the challenges in the sample size needed and in the constantly evolving biomarker land- scape and genomic and proteomic technologies. The statistical method used nearly exclusively to design and monitor clinical tri- als today, a method called frequentist or Neyman-Pearson (for the statisticians who advocated its use), is so narrowly focused and rigorous in its requirements that it limits innovation and learning. A solution is to adopt a system called the Bayesian method, a statistical approach more in line with how science works. The main dif- ference between the Bayesian approach and the frequentist approach to clinical tri- als has to do with how each method deals with uncertainty, an inescapable component of any clinical trial. Unlike frequentist methods, Bayesian methods assign anything unknown a probability using information from previous experiments. In other words, Bayesian methods make use of the results of previous experiments, whereas frequentist approaches assume we have no prior results. The Bayesian approach is better for doctors, patients who participate in clinical trials and for patients who are waiting for new treatments to become available. Physicians want to be able to design trials to look at multiple potential treatment combinations and use biomarkers to determine who is respond- ing to what medication. They would like to treat that patient optimally depending on the patient’s disease characteristics. If interim results indicate that patients with a certain genetic makeup respond better to a speciﬁc treatment, it is possible to recruit more of those patients to that arm of the study without compromising the overall conclusions. Use of the Bayesian approach may make it possible to reduce the num- ber of patients required for a trial by as much as 30 %, thereby reducing the risk to patients and the cost and time required to develop therapeutic strategies. Universal Free E-Book Store 594 20 Development of Personalized Medicine Using a Bayesian approach, contrary to the standard approach, the trial design exploits the results as the trial is ongoing and adapts based on these interim results. In order to have the personalized medicine, it will be necessary to be more ﬂexible in how we evaluate potential new treatments. Moreover, it is possible to reduce the exposure of patients in trials to ineffective therapy using the Bayesian approach. The size of this risk is likely to be conditioned by the underlying risk in a given patient of thrombosis and heart disease; the dose and duration of action of a drug; and the duration of dosing and concurrent therapies, such as low-dose aspirin. The researchers found a marked degree of variability in individuals dosed with either rofecoxib or celecoxib, even when they studied apparently healthy, relatively young individuals in a carefully controlled environment. This rigorous study suggests ~30 % of variability found in patients is attributable to differences between individuals, suggesting the contribution of genetics to a variety of bio- markers of drug response. Exploitation of variability in response can lead to tests which identify patients most likely to beneﬁt or suffer from drugs.