Biomedical subjects
Publications and source records attributed to P Berman.
OBJECTIVE: Our objective was to investigate the use of CT colonography in patients who have undergone incomplete colonoscopy. CONCLUSION: CT colonography is effective in evaluating portions of the colon not seen during colonoscopy and may have an adjunctive role.
The International Course in Healthcare Management is predicated on the belief that comparative benefits can most effectively be 'taught' by enabling students to work directly with colleagues in other countries, sharing views, discussing differences, and checking understandings on how healthcare is structured and managed in different countries. The course focuses on four countries--Canada, Germany, Finland and Ireland--which offer an interesting range and mix of approaches to healthcare, and yet are sufficiently similar to ensure relative ease of understanding. The course, which is delivered and taught jointly by faculty from five participating institutions in the four countries using the Internet as the distance delivery medium, is an integral component of each institution's participating department's graduate program. The aims of the course are: to enable the participants to develop an in-depth understanding of the healthcare systems of each country; to foster a deeper understanding, through comparative analysis, of each participant's own healthcare system; and to facilitate the development of new insights into ways of addressing common concerns in healthcare management. The course is structured around a series of case studies organized under four main themes: financing and funding; delivery issues; impact of health service reforms; and evidence-based management.
The United States is typically seen as an outlier in health spending when compared with other advanced nations. Recent improvements in health accounting in lower- and middle-income countries suggest some common features with the high and pluralistic spending in the United States. The author discusses recent developments and findings in health accounting outside the Organization for Economic Cooperation and Development (OECD) and their relevance for the United States. He argues that we should expect more fruitful exchanges in the future.
This paper estimates total expenditure on health care in Poland in 1994 and provides new evidence on high levels of private spending on health care. The analysis shows that health care expenditures in Poland are higher than has usually been maintained, and are comparable with the prevailing levels in many other European countries. Private expenditure on health is a significant proportion of total expenditure on health, and in particular on financing outpatient care. Available evidence indicates that informal payments made by patients to physicians contribute as much as double of the physician's salary, and thus form an important source of earnings for physicians. This situation of high private expenditures on health care and informal payments to physicians is likely to be true of other transitional economies of Central and Eastern Europe as well. One policy implication that emerges is these transitional economies face a big challenge in managing existing resources, as opposed to finding new resources, in the health sector more effectively to meet the health care needs of their population. The paper highlights the need for better understanding of the current availability and distribution of resources in the health sector and their directions of flow, in both public and private sectors, and suggests using tools such as National Health Accounts to track and monitor changes in the financing of the health care system.
The subunit vaccine for HIV-1, recombinant glycoprotein 120 (rgp120), was used as a model antigen to evaluate the potential for a pulsatile single immunization vaccine formulation consisting of poly(lactic-co-glycolic) acid (PLGA) microspheres. We designed rgp120 PLGA microsphere formulations that provide a pulse of rgp120 at 1 to 6 months (depending on the polymer) after administration, mimicking another immunization. In these studies, the in vitro pulse of rgp120 correlated well with the observed in vivo autoboost as measured by an increase in anti-gp120 antibodies in guinea pigs. The immune response to the rgp120 PLGA microsphere formulations was increased by adding the soluble form of the saponin-derived adjuvant, QS-21. The use of small microspheres, however, did not increase the humoral response to rgp120. A single immunization with rgp120 PLGA microspheres resuspended in soluble rgp120 and QS-21 elicited neutralizing antibody titers that were comparable to titers obtained from two immunizations of rgp120 and QS-21 at the same total dose. Administration of rgp120 PLGA microspheres in baboons resulted in high, long-lasting neutralizing antibody titers that were greater than repeated immunizations with soluble rgp120 and QS-21. These studies also indicated that a continuous release of QS-21 at the injection site may provide a greater immune response than a bolus injection. Overall, this work demonstrated that PLGA microsphere formulations may be designed to provide in vivo pulses of an antigen eliminating the need for repeated immunizations.
Given a strong match between regions of two sequences, how far can the match be meaningfully extended if gaps are allowed in the resulting alignment? The aim is to avoid searching beyond the point that a useful extension of the alignment is likely to be found. Without loss of generality, we can restrict attention to the suffixes of the sequences that follow the strong match, which leads to the following formal problem. Given two sequences and a fixed X > 0, align initial portions of the sequences subject to the constraint that no section of the alignment scores below -X. Our results indicate that computing an optimal alignment under this constraint is very expensive. However, less rigorous conditions on the alignment can be guaranteed by quite efficient algorithms. One of these variants has been implemented in a new release of the Blast suite of database search programs.
While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes.
PURPOSE: The aim was to identify stroke patients not admitted to hospital, to assess their disabilities and the rehabilitation provided. METHOD: Stroke patients were notified by General Practitioners, assessed a month after stroke on measures of impairment and disability and the rehabilitation received was recorded. There were 124 patients notified and 93 assessed. RESULTS: Patients showed an average decline of 1.7 on the Barthel Index and 3.6 on the Extended Activities of Daily Living scale from before to after stroke. There were 27% with severe mobility problems and 47% with clinically relevant arm impairment. Many patients had cognitive impairment with only 9% having no deficit. Mood problems were less common with 26% anxious and 13% depressed. Significant stress occurred in 15% of carers. The provision of rehabilitation was low and there was poor correspondence between impairments and services provided. CONCLUSION: There is an unmet potential for rehabilitation in stroke patients not admitted to hospital.
The inability of antibodies induced by experimental human immunodeficiency virus type 1 (HIV-1) vaccines to neutralize HIV-1 primary isolates may be due to a failure to elicit such antibodies, antigenic differences between the vaccine and the strains tested, insensitivity of the assays used, or to a combination of factors. New neutralization assays were used to determine the ability of candidate AIDS vaccines to generate neutralizing antibodies for clade B primary isolate BZ167, which is closely related in portions of its envelope to the immunizing strains. Sera from HIV-uninfected volunteers in vaccine trials were tested, and neutralizing activity was found in recipients of recombinant (r) gp120MN or of rgp160MN-containing canarypox boosted with rgp120SF-2. Detection of antibodies that neutralize primary isolate BZ167 correlated with neutralizing activity for homologous vaccine strains. These data demonstrate that certain candidate AIDS vaccines can elicit antibodies that neutralize a primary isolate of HIV-1.
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The aim of the study was to investigate the effect of perceptual assessment and treatment provided on a stroke unit by comparison with that provided on health care of the elderly and general medical wards. Stroke patients admitted to hospital were randomly allocated to a stroke unit or conventional wards. Perceptual impairment was assessed on entry to the study and at 3, 6 and 12 months after randomization. Stroke unit patients show significantly less impairment of perceptual abilities at all stages after stroke. Perceptual impairment, as assessed using the Rey figure copy, was a significant predictor of outcome as assessed on the Barthel Index, Extended ADL scale and Rivermead Motor Assessment at 12 months after stroke.
Evidence that women's employment and earnings foster increased allocations of household resources to children's well-being have led to advocacy of investment in women's employment as a method for targeting the social benefits of enhanced economic opportunity. Work and associated earnings are hypothesized to empower women, who can then exercise their individual preferences for spending on child well-being as well as influence household spending patterns. This paper presents results from a small detailed household and community study of maternal employment and child health in northern India (one of six studies in a research network), which sought to show that such effects did indeed occur and that they could be linked to work characteristics. Careful analysis of employment and earnings showed that they are multidimensional and highly variable over occupations and seasons. Contrary to expectations, spending on health care for children's illness episodes was negatively associated with maternal employment and earnings variables in econometric analysis. The expected individual effects on women of work and earnings, if they did occur, were not sufficient to alter the general spending pattern. We conclude that the attributes of work as well as the social and cultural environment are important mediators of such effects, suggesting a confluence of 'individual' and 'collective' behavioural determinants meeting in the locus of the household.
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Retail pharmacies in developing countries are one of the most important sources of advice on pharmaceuticals. Among the reasons the clients give are ease of access; availability of medicines; quality of service (no waiting and convenient hours of operation); and cheaper products, availability of credit, or the option to buy drugs in small amounts. However, the appropriateness of prescribing by retail pharmacy staff has been found to be far from acceptable. In childhood diarrhea, for example, oral rehydration salts (ORS), the appropriate diarrhea treatment, are recommended much less than pharmaceuticals of limited value, such as antimotility agents, adsorbents, etc. Little information is available for reasons underlying such behaviors. In this paper, we present a conceptual framework in which to analyze factors that may affect retail pharmacy prescribing, and we suggest strategies for behavior change. We developed this framework after examining relevant literature on retail pharmacy prescribing. We propose that pharmacy factors, client factors, physician practice and regulatory factors are the four sets of important factors for understanding pharmacy prescribing behavior. For intervention, we present four types of interventions which could be used for changing the behavior of pharmacy staff: information alone, persuasion, incentives and coercion. The behavior and intervention frameworks presented in this paper should also help in guiding further research in this area. For example, new information on the effects of ownership type, availability vs actual role of professional staff and authority structure on pharmacy treatment behaviors would be useful areas for future research. Similarly, additional research is needed on the comparative effects of coercive, persuasive and incentive strategies on pharmacy treatment behaviors.
This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries in Asia, Africa, and Latin America to explore the contribution of private health care providers to population coverage with a variety of maternal and child health and family planning services. The choice of countries and services assessed was mainly determined by the availability of data in the different surveys. Private providers contribute significantly to family planning services and treatment of children's infectious diseases in a number of the countries studied. This is as expected from the predictions of economic theory, since these goods are less subject to market failures. For the more 'public goods' type services, such as immunization and ante-natal care, their role is much more circumscribed. Two groups of countries were identified: those with a higher private provision role across many different types of services and those where private provision was limited to only one or two types of the services studied. The analysis identified the lack of consistent or systematic definitions of private providers across countries as well as the absence of data on many key services in most of the DHS surveys. Given the significance of private provision of public health goods in many countries, the authors propose much more systematic efforts to measure these variables in the future. This could be included in future DHS surveys without too much difficulty.
BACKGROUND AND PURPOSE: The aim of the study was to observe patients on a stroke unit and to compare their activity with that of patients on conventional hospital wards to identify aspects of rehabilitation practice that might account for differences in outcome. METHODS: Stroke patients admitted to the hospital were observed on three 8-hour shifts over 3 consecutive days. An observer recorded, at 10-minute intervals, where patients were, what they were doing, and whether their positioning was as recommended by rehabilitation therapists. Patients on a stroke unit were compared with those on conventional wards. RESULTS: Stroke unit patients spent less time by their beds and more time in other locations on the ward (P < .001). There were significant differences in the frequency of behaviors observed in the two types of ward (P < .001). Stroke unit patients had significantly more interaction with nurses and therapists (P < .001). They were also more often in the recommended position (P < .001). CONCLUSIONS: The proportion of time in therapeutic activity was low in all locations, with patients spending many hours sitting and doing nothing. Despite this, stroke unit patients had more therapeutic contact with staff and were more often in the recommended position. These two features may account for some of the differences in outcome.
Household survey data, time allocation data, and qualitative interviews were used to examine whether households allocate their resources for health care differently between age and gender groups. Households allocated significantly fewer resources to the health care of sick children compared to that of sick adults. In contrast there were no such differences with regard to gender. The underlying household rationale is to concentrate its resources spent for health care on productive members rather than to spread them equitably among all its sick members. While children are not productive, women were shown to contribute as much to household production as men, hence their health is valued equally with that of men. Unless we understand intra-household biases in resource allocation, policies will be undermined. Further research is needed to test the hypothesis for the households' preference of production maintenance over health maximization.
The composition of the hospital sector has important implications for cost effectiveness accessibility and coverage. The classification of acute general hospitals is reviewed here with particular reference to India and Andhra Pradesh. Approaches to arrive at a norm for allocation of hospital expenditure among secondary and tertiary hospitals are discussed. The actual allocation of public sector hospital expenditures is analyzed with data from Andhra Pradesh. The shift in allocative emphasis away from hospitals and in favour of primary health care during the 1980s was found to have been equally shared by secondary and tertiary hospitals. The shares of recurrent (non-plan) expenditure to secondary and tertiary hospitals were 51% and 49% respectively. This can be compared to a derived norm of 66% and 33%. The opportunity that new investment funds (plan schemes) could have provided to rectify the expenditure bias against secondary level hospitals was missed as two-thirds of plan expenditure were also spent on tertiary level hospitals. The share of secondary hospital bed capacity was 45.5% against India's Planning Commission norm of 70%. Public spending strategies should explicitly consider what mix of hospital services is being financed as well as the balance between hospital and primary health care expenditures.