Relationship of the medical profession to government supported alcoholism programs.
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Alcoholism↗
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America's children: economic perspectives and policy options.
American children are worse off than those in the previous generation in several important dimensions of mental, physical, and emotional well-being. During the 1960s cultural changes adversely affected children while their material condition improved substantially. By contrast, material conditions deteriorated in the 1980s, especially among children at the lower end of the income distribution. Public policies to improve the material condition of children require a transfer of resources from households that do not have children to those that do. Government programs such as tax credits and child allowances are more efficient and equitable than employer-mandated programs.
Adult↗
The health of U.S. hired farm workers.
Despite a recent surge in knowledge about U.S. hired farm workers, little is known about the health of this population. No national data are available on the size of the population, mortality or morbidity data, or on chronic health indicators. Demographic data show that these workers are mostly Mexican immigrant or migrant males, and nearly two thirds live in poverty. At least half of all current hired farm workers are undocumented. Fewer than one in five have health insurance, either through their employer or through government programs. However, programs targeting women farm workers, such as WIC or, in California, emergency MediCal, are more effective in helping them obtain needed services. The federal Migrant Health Program serves about 13% of the total of workers plus dependent family members. This paper reviews what is known in the following topical areas: (a) mortality and morbidity; (b) access to health care services; (c) control of infectious diseases; (d) maternal and child care; (e) occupational health; (f) violence; and (g) chronic health indicators. It is suggested that future research incorporate a minimal physical examination of all patients or subjects in order to establish baseline information for the population. Such information will be helpful in targeting interventions and measuring their effectiveness.
Agriculture↗
A cost-effectiveness evaluation of primary health care projects for the poor.
A cost-effectiveness analysis was conducted to determine the relative efficacy of nine primary health care projects serving low income persons in urban and rural areas of Texas. The projects were created as part of a government program to provide services in medically underserved areas of the state by contracting with local public and private providers. While they vary widely in terms of sponsoring organizations, service strategy, and scope of services, the projects share a similar goal of providing an array of basic medical and preventive care services to the poor. This study compares the average cost per encounter for diagnosis/treatment, emergency, family planning, and preventive health screening services provided by the various projects during the first year of operation. After adjusting for differences in input prices and patient volume, the cost differences are examined and related to organizational model and personnel mix. Those projects with the highest ratio of nonphysician to physician practitioners proved more cost-effective, as did those projects following the public clinic model of service delivery.
Community Health Centers↗
Loss of seizure control associated with generic substitution of carbamazepine.
OBJECTIVE: We report two cases of lost seizure control associated with the generic substitution of carbamazepine, review pertinent literature, and discuss the impact of this substitution on patient care. DATA SOURCES: Case studies, abstracts, and research publications identified in MEDLINE and bibliographic review. DATA EXTRACTION: One author reviewed cases supplied by the other authors and abstracted information from published literature sources. DATA SYNTHESIS: The first case describes a 15-year-old boy who received valproic acid and carbamazepine for partial seizures. A change in government program policies caused him to receive generic carbamazepine. This resulted in loss of seizure control and a decrease in his serum carbamazepine concentration from 12.4 to 6.7 micrograms/mL. When his carbamazepine concentration returned to previous levels, seizure control was not reestablished. A second case involves a 21-year-old woman who substituted generic carbamazepine because of financial problems. After being seizure-free for at least five years on phenobarbital and carbamazepine, she experienced seizures related to the product change. Her carbamazepine concentration decreased from 11.8 to 8.5 micrograms/mL; she also became pregnant at that time. Seizure control was not reestablished. At least three other studies do not support these observations, but the tightly controlled conditions in these studies may not have simulated actual clinical practice. CONCLUSIONS: When generic substitution of carbamazepine is required, serum concentrations should be carefully monitored. The extra care required may negate the financial advantages of the substitution.
Adolescent↗
The relationship between differentiation and proliferation in late gestation fetal rat hepatocytes.
Hepatocyte proliferation and differentiation occur simultaneously during late mammalian gestation. We hypothesized that regulation of hepatocyte growth and differentiation would be coordinated in late gestation fetal hepatocyte cultures such that proliferation would be most active in a population of less well-differentiated cells. Cultured fetal hepatocytes (embryonic d 19 and 21; E19 and E21) were studied using double staining immunofluorescent microscopy. Differentiation was assessed as staining for alpha-fetoprotein (AFP), three markers of enzymic differentiation (glucokinase [GK], phosphoenolpyruvate carboxykinase [PEPCK], and carbamoyl phosphate synthase [CPS]), and a hepatocyte cell-cell adhesion molecule (C-CAM). Proliferation was assessed using immunocytochemical detection of proliferating cell nuclear antigen (PCNA) or 5-bromo-2'-deoxy-uridine (BrdU) incorporation into DNA. Fetal hepatocyte cultures consisted of a heterogeneous population of cells, slightly more than half of which were proliferative under defined, growth factor-free conditions. These cultures were heterogeneous for AFP expression. There was no correlation between the expression of AFP and PCNA or AFP and S-phase entry (BrdU staining) during the first 48 h in culture. Similar results were obtained in staining for the enzymic differentiation markers and C-CAM. In addition, the differentiation status of cultured fetal hepatocytes was unrelated to a presumed indicator of mature growth regulation, mitogenic responsiveness to transforming growth factor alpha (TGFalpha), and hepatocyte growth factor (HGF). Finally, absence of any correlation between proliferation and differentiated phenotype was supported by in vivo studies using staining for PCNA, AFP, CPS, and PEPCK in liver sections. These results indicate that the developmental program governing differentiation of late gestation fetal rat hepatocytes is independent from mechanisms controlling proliferation.
Animals↗
Transcriptional regulation of cardiac development: implications for congenital heart disease and DiGeorge syndrome.
In recent years, impressive advances have occurred in our understanding of transcriptional regulation of cardiac development. These insights have begun to elucidate the mystery of congenital heart disease at the molecular level. In addition, the molecular pathways emerging from the study of cardiac development are being applied to the understanding of adult cardiac disease. Preliminary results support the contention that a thorough understanding of molecular programs governing cardiac morphogenesis will provide important insights into the pathogenesis of human cardiac diseases. This review will focus on examples of transcription factors that play critical roles at various phases of cardiac development and their relevance to cardiac disease. This is an exciting and burgeoning area of investigation. It is not possible to be all-inclusive, and the reader will note important efforts in the areas of cardiomyocyte determination, left-right asymmetry, cardiac muscular dystrophies, electrophysiology and vascular disease are not covered. For a more complete discussion, the reader is referred to recent reviews including the excellent compilation of observations assembled by Harvey and Rosenthal (1).
Abnormalities, Multiple↗
Understanding physicians' decisions to practice in rural areas as a basis for developing recruitment and retention strategies.
The shortage of providers in rural areas is threatening the quality and availability of health care in many communities. The causes of the provider shortage are many and varied-from economic to social to personal. Government programs have addressed the issue of provider supply by offering scholarships and loan repayment programs for medical students who then must fulfil service obligations in underserved settings, among which are rural areas. Experience has shown that once providers complete their obligations under these grant programs, retention of providers in rural areas becomes an even more critical issue. Using focus group research, this study explores the practice setting choices of a group of physicians currently practicing in rural areas. The discussion reveals that personal values are one of the primary motivators for choosing to practice in rural settings while lack of availability of career opportunities for spouses and educational opportunities for children are major obstacles. The health care system poses barriers to success for providers in rural settings. The key rewards from rural practice are the ability to become integrated into the local community and the provider/patient relationships that develop in such settings. These findings are used as the basis for proposing recruitment and retention strategies for providers to improve access to medical care by patients in rural areas.
Career Choice↗
Infant feeding styles: barriers and opportunities for good nutrition in India.
India has the lion's share of malnourished children in the world. Poverty and social exclusion contribute to this rate of malnutrition, but care practices also play a role. Breastfeeding is rarely exclusive, sanitation tends to be limited, complementary feeding often begins late, and the quantities are small. In the past, government programs have focused on the supply of food rather than caring practices. A research agenda will include both operational research on the nutrition programs, and formative and intervention research to improve caring practices, particularly those around infant and young child feeding.
Bottle Feeding↗
Spatiotemporal profile of an optimal host response to virus infection in the primate central nervous system.
Viral infections of the central nervous system (CNS) are a major cause of morbidity largely due to lack of prevention and inadequate treatments. While mortality from viral CNS infections is significant, nearly two thirds of the patients survive. Thus, it is important to understand how the human CNS can successfully control virus infection and recover. Since it is not possible to study the human CNS throughout the course of viral infection at the cellular level, here we analyzed a non-lethal viral infection in the CNS of nonhuman primates (NHPs). We inoculated NHPs intracerebrally with a high dose of La Crosse virus (LACV), a bunyavirus that can infect neurons and cause encephalitis primarily in children, but with a very low (≤ 1%) mortality rate. To profile the CNS response to LACV infection, we used an integrative approach that was based on comprehensive analyses of (i) spatiotemporal dynamics of virus replication, (ii) identification of types of infected neurons, (iii) spatiotemporal transcriptomics, and (iv) morphological and functional changes in CNS intrinsic and extrinsic cells. We identified the location, timing, and functional repertoire of optimal transcriptional and translational regulation of the primate CNS in response to virus infection of neurons. These CNS responses involved a well-coordinated spatiotemporal interplay between astrocytes, lymphocytes, microglia, and CNS-border macrophages. Our findings suggest a multifaceted program governing an optimal CNS response to virus infection with specific events coordinated in space and time. This allowed the CNS to successfully control the infection by rapidly clearing the virus from infected neurons, mitigate damage to neurophysiology, activate and terminate immune responses in a timely manner, resolve inflammation, restore homeostasis, and initiate tissue repair. An increased understanding of these processes may provide new therapeutic opportunities to improve outcomes of viral CNS diseases in humans.
Animals↗
Risk factors for prophylaxis failure in patients receiving aerosol pentamidine for Pneumocystis carinii pneumonia prophylaxis.
OBJECTIVE: The purposes of this study were (1) to determine the incidence of prophylaxis failure in HIV-infected patients receiving aerosol pentamidine (AP) for Pneumocystis carinii pneumonia (PCP) prophylaxis, and (2) to identify risk factors for PCP prophylaxis failure. SETTING AND DESIGN: In Ontario, Canada, AP has been made available for outpatient PCP prophylaxis through a centralized government program, the Ontario Drug Distribution and Monitoring Program. Data from this administrative observational database were extracted for 2,227 patients who received AP between May 1989 and December 1998. OUTCOME MEASUREMENTS: The incidence of breakthrough PCP (BPCP) was calculated from the database. A Cox regression model with time-varying covariates was created to examine factors associated with BPCP. The follow-up time was divided into three eras: 1989 to 1991, 1992 to 1994, and 1995 to 1998. These eras were meant to reflect major changes in antiretroviral medication regimens. RESULTS: The overall risk of BPCP was 16.2% over a mean follow-up of 1.67 years. The overall BPCP rate was 9.7/100 patient-years, with rates of 8.8/100, 13.1/100, and 6.3/100 patient-years in each of the three treatment eras. In the multivariate analysis, significant risk factors for prophylaxis failure were low CD4 count, previous diagnosis of PCP, history of AIDS-defining conditions other than PCP, and antiretroviral treatment era defined above. CONCLUSION: The overall rate of PCP prophylaxis failure has decreased significantly after 1995, coincident with the era of highly active antiretroviral therapies. Initiation of PCP prophylaxis remains necessary in patients with risk factors.
Adult↗
[Community health centers: an alternative for the health system]
Reflecting on the current reorganization of the relationship between the state and civil society, the health care field is involved in an intense debate over the organization and use of government and private health services. The authors propose an alternative, consisting of the implementation of primary health care clinics, managed by local institutions and funded by the Unified Health System. To support this proposition, they report on the current experience at the Rocinha slum in Rio de Janeiro, where a community health center was built by the neighborhood association 12 years ago and has been managed by the community since then. The hospital referral rate at the clinic, requests for laboratory tests, and use of precriptions have been considerably limited, although these services are available. These low rates are attributed to the possibility of closer social control by the community, as well as to the geographical features of the center, favoring a broader perception of both health problems and treatment. In order to provide more substantial support to the proposed centers, some suggestions are presented, like the implementation of direct agreements between the government and neighborhood associations (not allowed under current legislation) and expanding potential sources of funding for the health centers, currently restricted to government programs.
Journal Article↗
An international look at school-based children's dental services.
School-based dental clinics, when well-managed, can bring good quality care to children where they normally congregate, thus avoiding many of the problems found where children must be taken to private offices out of school hours. Both capital and running expenses for primary care can be substantially reduced. Utilization figures for school-based dental services now reach 98 per cent of eligible children in New Zealand, where dental nurses do simple operative dentistry including cavity preparation and fillings. Australia, where a modified New Zealand plan has been expanding for about 12 years, is moving rapidly to attain similar utilization. In Sweden, 95 per cent of the school-age population is reported to receive school-managed dental service through a government program. In the United States, however, it is commonly reported that less than one-half the school-age population receives good periodic dental care.
Adolescent↗
Political identification and perceptions of homelessness: attributed causality and attitudes on public policy.
The study investigated relationships between political orientation, causal perceptions of poverty, and attitudes toward government programs for the poor. The test sample of 200 women and 200 men were recruited from introductory psychology classes. In support of hypotheses based on previous research and Weiner's attribution-emotion-action theory, when compared with self-identified Democrats, self-identified Republicans (a) were significantly more inclined to attribute homelessness to internal vs external factors and (b) expressed significantly less favorable attitudes toward publically funded programs for the homeless. Sex differences were nonsignificant. Conceptual-empirical and methodological implications are discussed. Limitations on inferences from these data and directions for inquiry into the development of individual difference in political cognitions and public policy attitudes are considered.
Adult↗
Swimming Upstream to Understand Congenital Anomalies of the Kidney and Urinary Tract: Zebrafish Models for Developmental Biology, Disease Mechanisms, and Functional Interpretation of Genetic Variation.
Congenital anomalies of the kidney and urinary tract (CAKUT) are the leading cause of pediatric chronic kidney disease (CKD) and comprise a heterogeneous group of developmental disorders with a substantial genetic contribution. Advances in next-generation sequencing have facilitated the identification of numerous candidate genes and rare variants associated with CAKUT. However, establishing causality and defining the biological functions of implicated genes remain major challenges. Functional validation is therefore essential to bridge the gap between gene discovery and mechanistic understanding, enabling the interpretation of genetic variation within the context of kidney development and disease. The zebrafish (Danio rerio) has emerged as a powerful in vivo model for studying renal development and interrogating the function of CAKUT-associated genes. Its utility stems from a high degree of genetic and developmental conservation with humans, conserved nephrogenic pathways, optical transparency during embryogenesis, and the relative ease of genetic manipulation. In this review, we provide an overview of zebrafish kidney development within the broader context of vertebrate nephrogenesis, highlighting the key genetic programs governing intermediate mesoderm specification, nephron segmentation, and pronephric morphogenesis. We then systematically examine CAKUT-associated genes that have been modeled in zebrafish, focusing on studies that have linked genetic perturbations to renal development and structural phenotypes. Finally, we discuss the strengths and limitations of zebrafish models for functional genomics and variant interpretation and consider their emerging role in bridging genetic discovery with mechanistic insights into CAKUT pathogenesis.
Animals↗
Point/counterpoint: national health insurance.
In early November at the annual Board of Directors meeting of the Federation of American Health Systems, Chrysler Corporation's Walter B. Maher spoke for health care reform, stressing a need for a strong government solution. Humana Inc.'s George Atkins rose to the defense of the health care industry and countered Maher's ideas with his case for expansion of existing government programs coupled with a larger share of cost responsibility falling to employees.
Costs and Cost Analysis↗
Retooling for community benefit.
Healthcare providers today must have a mission of service both to the individual and to the community. In 1990 the Hospital Community Benefit Standards Program (HCBSP) was launched as a demonstration project to begin the process of defining the elements that constitute community benefit. The HCBSP standards are that a hospital (1) evince a significant organizational and operational commitment to a community benefit process, (2) plan and implement projects and activities that address specific community public health needs, (3) cultivate and maintain relationships with other organizations to foster community benefit, and (4) foster an internal environment that encourages everyone in the organization to participate in community benefit programs. The following elements are important to an effective community benefit program: Governing board involvement CEO understanding and commitment A key senior manager to coordinate An explicit commitment of human and financial resources An epidemiologic data base describing a defined community or population A mechanism for bringing together people in the organization interested in community benefit A mechanism for facilitating dialogue between hospital leaders and representatives from the community A method of linking community benefit processes to outcomes
Chief Executive Officers, Hospital↗
Pharmaceuticals in Australia: priorities in a teaching hospital.
In spite of rigorous government programs for control of the pricing and dissemination of pharmaceutical products in Australia, the list of new drugs continues to grow and prices to increase. To regain control over drug usage at Royal Adelaide Hospital, the Hospital Drug Committee developed a rating method that judged drugs on the basis of their cost-benefit to patients. The ratio of a total quality score to a total cost score becomes the determinant of additions to the hospital formulary. The background for the Australian approach to pharmaceuticals and the new evaluation technique at the teaching hospital are described in this report.
Australia↗