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Biomedical subjects

R A Epstein

Publications and source records attributed to R A Epstein.

At least 19 recordsLinked to original sources
PubMed2006

Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage.

Availability of kidney transplantation is limited by an inadequate supply of organs, with no apparent remedy on the immediate horizon and increasing reliance on living donors (LDs). While some have advocated financial remuneration to stimulate donation, the National Organ Transplant Act (NOTA) of 1984 expressly forbids the offer of 'valuable consideration.' However, recent developments indicate some fluidity in the definition of valuable consideration while evolving international standards highlight deficiencies (particularly regarding long-term care and follow-up) in the current American system. Recognizing that substantial financial and physical disincentives exist for LDs, we propose a policy change that offers the potential to enhance organ availability as well as address concerns regarding long-term care. Donors assume much greater risk than is widely acknowledged, risk that can be approximated for the purpose of determining appropriate compensation. Our proposal offsets donor risk via a package of specific benefits (life insurance, health insurance and a small amount of cash) to minimize hazard and ensure donor interests are protected after as well as before nephrectomy. It will fund medical follow-up and enable data collection so that long-term risk can be accurately assessed. The proposal should be cost effective with only a small increase in the number of LDs, and the net benefit will become greater if removal of disincentives stimulates even further growth. As importantly, by directly linking compensation to risk, we believe it preserves the essence of kidney donation as a gift, consistent with NOTA and implementable in the United States without altering current legal statutes.

Costs and Cost Analysis↗
PubMed1999

Managed care under siege.

Managed Care Organizations (MCOs) are frequently criticized for their marketing mistakes. Often that criticism is leveled against an implicit benchmark of an ideal competitive market or an ideal system of government provision. But any accurate assessment in the choice of health care organizations always requires a comparative measure of error rates. These are high in the provision of health care, given the inherent uncertainties in both the cost and effectiveness of treatment. But the continuous and rapid evolution of private health care mechanisms is, in the absence of regulation, more likely to secure access and contain costs than any system of government regulation. State regulation is subject to the risk of capture and to the sluggish and acquisitive behavior of state run monopolies. The proposed fixes for the MCOs (rights to specialists, access to physicians outside the network, guaranteed emergency room access) are likely, when imposed from without, to cost more than they are worth. The long-term risk is that markets will fail under regulation, paving the way for greater losses from massive government control of the health care delivery system.

Benchmarking↗
PubMed1998

Living dangerously: a defense of Mortal Peril.

As one of the most controversial writers of our time, just the name Richard Epstein draws immediate attention from all sectors of academia. But if the hallmark of great ideas is the criticism they engender, Professor Epstein's words and thoughts are powerful indeed. In Mortal Peril, Professor Epstein outlined a fundamental shift in thinking that he claimed needed to occur before any discussion of health care could take place. The final consensus of the validity of Professor Epstein's views may still be a matter for history to judge, but in many ways, he has already won; with the strength of his logic and convictions, he has forced other scholars to address his concerns, and in doing so, he has refocused the debate on health care. At the symposium, Professor Epstein proved his indisputable eloquence and debating skill in answering and refuting the various points made by his many critics. Now, in writing, he thoughtfully considers and analyzes the views submitted by his colleagues, and solidifies the ideas that first found their expression in Mortal Peril.

Delivery of Health Care↗
PubMed1994

Small cell carcinoma of the lung metastatic to the wall of a radicular cyst.

This case report details the unusual presentation of small cell carcinoma at the periapex of a maxillary left lateral incisor. The initial clinical presentation was that of a symptomatic, nonhealing, well-circumscribed radiolucency about the periapex of the tooth. The biopsy specimen submitted by the endodontist was diagnosed as small cell carcinoma. This report stresses the need for submission of all tissue removed from the oral cavity for histopathological examination.

Aged↗
PubMed1990

Assessment of suitability for low-fee control psychoanalysis: some theoretical and technical considerations.

In the assessment of suitability for low-fee control analysis, various factors may interfere with successful referral, evaluation, and disposition. Variables within the referring analyst, patient, candidate, and supervisor are examined in their interaction with the circumstances of the assessment enterprise. Issues of competence, self-esteem, and oedipal rivalry, as well as guilt feelings, concerns about rejection, and other conflicts may be mobilized and may prevent a successful outcome. Clinical data from three assessments are presented and discussed. The concept of an assessment process, analogous to the psychoanalytic process, is proposed. In this process, manifestations of the patient's intrapsychic life and indicators of potential transferences emerge in the context of the analysis of the patient's reactions to the assessment. Potential sources of interference with the assessment process are identified, and measures to avoid them are suggested.

Adult↗
PubMed1988

Frequency dependence of dead space during high-frequency ventilation in rhesus monkeys.

A rotary valve ventilator, designed to allow the direct measurement of expired gas volume and composition, was used to maintain gas exchange in anesthetized, paralyzed, rhesus monkey at ventilatory frequencies up to 20 Hz. A total of five studies were carried out on three animals. Determinations of the minute ventilation required to maintain a normal steady-state PCO2, together with the FECO2 and arterial PO2, PCO2, and pH, were made at a number of frequencies. The results so obtained were used to calculate the Bohr (physiological) dead space. Dead space remained approximately constant at close to the value determined during spontaneous ventilation for each individual animal in the range of ventilatory frequencies from below 1 to around 5 Hz, but decreased somewhat with increasing frequency above 5 Hz. The calculated physiological dead space at 15 Hz was about 70% of the value at normal respiratory frequencies. These findings in primates, obtained using a ventilator system which allows very accurate determinations of expired gas volume and content, when compared with those from our previous studies in rabbits and dogs, provide further evidence that the relationship between efficiency of gas exchange and ventilatory frequency during HFV is highly species-specific.

Animals↗
PubMed1988

Effective dead space of differently shaped airways during high-frequency ventilation of a CO2-producing lung model.

A simple lung model is described which simulates the mechanical properties and CO2 production of the lungs of a small animal, and which can be used with high-frequency ventilators. The model was ventilated by a rotary-valve ventilator and the system was used to determine the increment in 'physiological' (Bohr) dead space produced at various ventilatory frequencies between 0.5 and 15 Hz by the insertion of various additional volumes and configurations of 'anatomical' dead space in its 'upper airway'. It was found that the insertion of a straight tube with an internal diameter similar to that of the ventilator outlet tube produced an increment in 'physiological' dead space that remained commensurate with the volume of the added tube at all combinations of the tube volume and ventilatory frequency. The insertion of similar volumes of dead space in the form of tubes with smoothly expanded central portions produced increments in 'physiological' dead space which were commensurate with the volume of the added tube only at the lowest frequencies, and actually became negative at higher frequencies and volumes. These findings provide further evidence that the volume and configuration of the external portion of a high-frequency ventilator system may be of at least as much importance in determining its efficiency as is the lung structure of the animal or patient being ventilated.

Animals↗
PubMed1986

Frequency dependence of dead space during high-frequency ventilation in dogs.

A rotary valve ventilator, designed to allow the direct measurement of expired gas volume and composition, was used to maintain gas exchange in anesthetized, paralyzed, mongrel dogs at ventilatory frequencies up to 20 Hz. A total of eleven studies were carried out on four animals. Determinations of the minute ventilation required to maintain a normal steady-state PCO2, together with the FECO2 and arterial PO2, PCO2, and pH, were made at a number of frequencies. The results so obtained were used to calculate the Bohr (physiological) dead space. Dead space remained approximately constant at close to the value measured during spontaneous ventilation for each individual dog in the range of ventilatory frequencies from below 1 to around 5 Hz, but decreased with increasing frequency above 5 Hz. The calculated physiological dead space at 15 Hz was about half of the value at normal respiratory frequencies. These findings in dogs, obtained using a ventilator system which allows very accurate determinations of expired gas volume and content, are consistent with published results for this species from other laboratories. They contrast with our earlier findings in rabbits that dead space remains constant with increasing frequency, suggesting that the effects of high-frequency ventilation on CO2 transport are species-dependent.

Animals↗
PubMed1985

Soda lime adsorption of isoflurane and enflurane.

The authors demonstrated that soda lime will adsorb enflurane or isoflurane as a function of the water content of the soda lime. Various volumes of liquid enflurane or isoflurane were placed in an equilibration flask containing fresh (15% water by weight) or dried soda lime and the vapor phase anesthetic concentrations plotted. When dry soda lime was used, the plot of concentration as a function of volume of liquid added was biphasic: initially flat and then rising linearly. This is qualitatively similar to data reported previously for halothane. The authors hypothesize that drying soda lime produces a molecular sieve-like structure, as adsorption is greatest for molecules with small carbon chain lengths and kinetic diameters, or with structural characteristics such as cis/trans isomerism, which effectively reduce molecular size.

Adsorption↗