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PubMed1995

Legal obstacles to medical communities' full participation in managed care.

Strong physician-driven delivery systems are vital to the creation of a quality medical system for the United States. To compete with employers, insurers, hospitals, and the government, physicians must consolidate. Physicians do not generally have the necessary capital, management skills, or desire to manage large organizations, however. In addition, antitrust restrictions, antireferral statutes, insurance regulation, and malpractice liability risks are major legal obstacles that restrain physicians from consolidating. The government needs to recognize the problems that federal and state laws have created for the development of physician-driven delivery systems. The benefit to the medical system by relaxing these laws will outweigh any potential risk of loss to the public.

Antitrust Laws↗

PubMedDate not supplied

The Minnesota Prenatal Care Coordination Project: successes and obstacles.

The Minnesota Prenatal Care Coordination Project was a statewide effort to present systematically education and technical support to providers as they implemented the Minnesota Prenatal Care Initiative for expanded services to high-risk women. Educational methods included holding 12 regional workshops throughout the State, one-to-one contacts by nurse consultants, and newsletters and a guidebook (manual) were distributed to reach community providers. Analysis of the implementation was conducted using site visits, interviews with providers, and reviews of medical records, claims data, and other project documents. Successes in the first year were a twofold increase in the numbers of Medicaid-enrolled women who received risk assessment and enhanced services, more than one-third increase in provider participation, greater collaboration among multidisciplinary providers at the community level, and improved communication between State and local health care agencies. Obstacles included provider resistance to changes in practice, dissatisfaction with the enhanced services package and level of reimbursement, and problems with implementation protocols. The project demonstrated that prenatal care providers will change; they will improve practices and collaboration as a result of personalized education and support.

Female↗

PubMed1994

[The nursing situation in the old and new parts of the Federal Republic of Germany: a comparison of requirements, obstacles and nursing autonomy].

Differences with regard to demands, obstacles and elbow room, affecting nursing activities in general hospitals are examined. An instruments measuring various facets was devised (TAA KH). The results reveal that in all three areas there are significant differences between activities of nursing staff in East and West German Hospitals. The differences are being discussed against the background of the situation in the new Bundesländer.

Germany, East↗

PubMedDate not supplied

HIV prevention in prisons and jails: obstacles and opportunities.

High rates of human immunodeficiency virus (HIV) infection among jail and prison inmates suggest that HIV prevention efforts should focus on incarcerated populations. Overcrowding, the high prevalence of injection drug use, and other high-risk behaviors among inmates create a prime opportunity for public health officials to affect the course of the HIV epidemic if they can remedy these problems. Yet, along with the opportunity, there are certain obstacles that correctional institutions present to public health efforts. The various jurisdictions have differing approaches to HIV prevention and control. Whether testing should be mandatory or voluntary, whether housing should be integrated or segregated by HIV serostatus, and whether condoms, bleach, or clean needles should be made available to the prisoners, are questions hotly debated by public health and correctional officials. Even accurate assessment of risk-taking within the institutions leads to controversy, as asking questions could imply acceptance of the very behaviors correctional officials are trying to prevent. Education and risk-reduction counseling are the least controversial and most widely employed modes of prevention, but the effectiveness of current prevention efforts in reducing HIV transmission in this high-risk population is largely undetermined.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Institutional obstacles to educational reform.

For the full implications of health care reform to be implemented in health professions education, there will need to be a radical rethinking of educational missions and goals, as well as a careful analysis of the obstacles to educational reform that are currently extant within our academic centers and health professions schools. A series of steps should be taken to encourage the development of a collegial spirit among faculty and students across the major health professions. As costs of education become distinct from those of service and research, certain organizational steps will become apparent, such as: 1) developing separate postgraduate and undergraduate medical schools; and 2) forming a regional educational network to respond to the workforce demands of the region.

Faculty↗

PubMed1994

Understanding cultural obstacles to HIV/AIDS prevention in Africa.

Global efforts to prevent further spread of the human immunodeficiency virus (HIV) are faced with tremendous obstacles, and limited understanding of the cultural and social context of HIV and AIDS is an important factor hindering prevention efforts to date. Examples from the authors' experience in providing technical support to 7 nongovernmental projects for HIV/AIDS prevention in Africa illustrate the importance of including qualitative data in initial baseline studies for projects responding to the problem. Qualitative data are needed to provide a deeper understanding of the meanings of behavior and other phenomena that are identified through quantitative methods. Runyoka is discussed as an example of a traditionally-defined illness in Zimbabwe that appears to affect local understanding of HIV/AIDS. The authors suggest approaches that would assist HIV/AIDS projects to better understand and respond to the social and cultural context of AIDS in local settings.

Africa↗

PubMed1994

Obstacles to the accrual of patients to clinical trials in the community setting.

Data indicate that substantial pool of candidates exists, especially in the community setting, for enrollment in clinical oncologic trials. However, only a small proportion of cancer patients are actually enrolled. Obstacles to accrual include physician determinants, patient determinants, organizational issues, and health care system factors. Physicians can influence patient enlistment in their capacity as either referring physician or study investigator. A practitioner's medical orientation may impact the likelihood of referral. Physicians reluctant to enroll patients cite logistic and practical problems and the potential for disrupting patient relationships; a trial's protocol also may be questioned. Patient refusals to participate in clinical trials may stem from practical concerns, psychosocial issues, or a wariness of toxic treatment effects. Organizational issues affecting patient accrual have not been extensively studied; an institutional review board's view of research may be a major factor. Health care system factors such as escalating costs and prohibitive reimbursement policies of third-party payers also adversely affect accrual, and will require a new commitment to minimizing protocol costs. Continued evaluation of physician and patient barriers to accrual is warranted. Once these barriers are recognized, randomized intervention trials will be required to identify ways to overcome them.

Clinical Trials as Topic↗

PubMed1996

Necrotizing soft tissue infections: obstacles in diagnosis.

BACKGROUND: This study was done to identify obstacles in the early diagnosis and treatment of necrotizing soft tissue infections. STUDY DESIGN: A ten-year retrospective case series was analyzed. RESULTS: Data from 29 patients were analyzed. Among patients undergoing early operation within 24 hours of admission (n = 17) there was one death (6 percent mortality rate); survivors averaged 2.9 operations per patient. By comparison, of patients with delayed operation (n = 12) three died (25 percent mortality rate) and there were 3.6 operations per patients. Positive fine-needle aspiration (FNA) of suspicious lesions, demonstrating either pus or bacteria by Gram's stain, led to early operation in 80 percent of patients tested. Patients with soft tissue gas on radiographs were more likely to undergo early operation (58 percent). Delayed operation was more common in the absence of radiographic findings. All patients admitted to nonsurgical services had delayed operations. CONCLUSIONS: Suspected necrotizing soft tissue infections require prompt surgical evaluation and early operative exploration. Early operation with definitive surgical therapy initiated within 24 hours of admission is associated with decreased mortality rates. Negative FNA findings, nondiagnostic radiographs, and admission to a nonsurgical service correlate with delay in definitive operative intervention.

Adolescent↗

PubMed1995

Countertransference as instrument and obstacle: a comprehensive and descriptive framework.

A comprehensive and descriptive approach to counter-transference phenomena is proposed. Three types of mental activity are distinguished: the objective-rational attitude is an adaptive, relatively nondefensive mode of observation; the reactive mental state corresponds to the classical notion of unconscious counter-transference as an obstacle and a defense; by contrast the reflective attitudes involve preconscious and conscious psychical activity. Reflective activity involves four phases: (1) during emergence, an inner reaction appears; (2) immersion, through a regressive exploration, leads to introjective identification; (3) integrative elaboration involves a shift in cathexis, more distance, and an organization of the regressed contents, while (4) an interpretation is forming in mind. Three case examples from the literature serve to illustrate.

Countertransference↗

PubMed1996

Prevention in managed care: obstacles and opportunities.

Managed care will present many new challenges to health care providers in their efforts to improve the quality of the preventive care their patients receive. Managed care will present both formidable obstacles to prevention and previously unknown opportunities to enhance population-based preventive services. Whether these opportunities are realized depends on the degree and quality of the involvement of health care providers in managed care institutions. Provider and public health input is particularly needed to promote the development of uniform preventive care standards, the development of information systems for continuous monitoring of preventive service delivery, and to enhance clinic-based preventive efforts, and the development of reimbursement mechanisms that provide incentives for prevention. Independent research and oversight is needed to show the impact of various types of managed care on preventive service delivery and quality of care. The effects of managed care on the preventive care that patients receive will ultimately be determined by the quality, priorities, and determination of the management.

Forecasting↗

PubMed1996

Pediatric palliative medicine: obstacles to overcome.

The care of the dying child involves an appreciation of issues that are distinct from those faced in adult palliative care. Obstacles to effective palliative care for children start with the very basic need to assure pain control, and include difficult ethical issues of limits to treatment and the determination of the child's best interests. The remarkable progress in medicine has resulted in the ability of medical science to more accurately diagnose and treat most symptoms of the terminally ill. What remains underrepresented is the teaching and application of the tools at hand that can provide comfort and relief to the dying. In children, an appreciation of the whole person, including the unique role of parents, is needed when we are confronted with the difficult choices faced at the end of life. Given the lack of objective data on such basic issues as the assessment of pain, the relationship of thirst to dehydration, and the ability of technology to prolong the quality of life, it remains imperative that we remain open to different interpretations of the appropriate use of medical therapies. In areas such as the pharmacodynamics of opiates, where good data already exist, it remains unacceptable to have children suffer because of misperceptions and incorrect assumptions about appropriate drug use. The task of understanding the complexity of the child and family as they live through the experience of the child's dying is enormous. The need to give care and attempt the relief of suffering is just as great as the need to cure and should be no less an ultimate goal of medicine.

Adolescent↗

PubMed1996

Obstacles to extending fluoridation in the United States.

The purpose of this paper is two-fold: (1) to describe the current extent of water fluoridation in the United States; (2) to address the major obstacles to attaining 75 per cent fluoridation by the year 2000. While 62.1 per cent of the US population has access to fluoridated public water systems, more than 32 million people need to be added to the fluoridation census, primarily from the cities. The legal framework for implementing fluoridation is considered at the state level; a review of fluoridation actions at the local level is presented. The impact of forces affecting the extension of fluoridation in the United States is described: (1) demographic trends--urbanisation, race, ethnicity, language, immigration, age, education levels, housing, income and poverty levels; (2) external environmental forces/political climate; (3) media influence on public opinion and public policy; (4) voter apathy/lack of awareness of the benefits of fluoridation; (5) perceptions of risks vs. benefits; (6) lack of political campaign skills; and (7) legal issues.

Fluoridation↗

PubMed1997

Routine molecular genotyping of HLA-B27 in spondyloarthropathies overcomes the obstacles of serological typing and reveals an increased B *2702 frequency in ankylosing spondylitis.

OBJECTIVE: To evaluate the reproducibility and reliability of polymerase chain reaction (PCR) in HLA-B27 typing compared to the conventionally used microlymphocytotoxicity test (MLCT). To determine the HLA-B27 subtype frequencies (B*2701-B*2709) in patients with HLA-B27 associated disease and healthy persons using sequence specific oligonucleotides (SSO). METHODS: 398 consecutive patients were HLA-B27 typed by MLCT and PCR. Subtyping by SSO was performed in 142 patients with HLA-B27 associated disease [ankylosing spondylitis (AS) n = 38, reactive arthritis 44, undifferentiated spondyloarthropathy (uSpA) 45, psoriatic arthritis 15] and 125 healthy HLA-B27 controls. RESULTS: MLCT identified 61 HLA-B27 positive patients (15.3%); PCR identified 78 positive patients (19.6%). MLCT gave false negative results for 8 patients (2.0%) and false positives for a further 7 (1.8%). Only subtypes B*2702 and B*2705 were present in patients and controls. Overall frequencies of B*2702 in patients and controls were 14.1 and 9.6%, respectively. The B*2702 frequency was significantly (pcorr. < 0.04) higher in AS (23.7%) and lower in uSpA (6.7%) patients. CONCLUSION: HLA-B27 typing by PCR is reliable and reproducible and therefore recommended for routine typing. It overcomes the obstacles of serological typing, i.e., equivocal results and cross-reactivity. In addition, subtype frequencies (B*2702 and B*2705) are equally distributed among patients and controls, although subtype B*2702 seems to be more frequent in AS and less so in uSpA.

Amino Acid Sequence↗

PubMedDate not supplied

[The reduction of mother-child transmission of HIV infection in developing countries: potential intervention strategies, obstacles to implementation and perspectives. The Reduction of Mother-Child Transmission of HIV Infection in Africa Group].

Mother to child transmission (MCT) of Human Immunodeficiency Virus (HIV) is the main cause of the spread of the HIV epidemic in the pediatric population. It is estimated that to date, three million children worldwide have been infected by HIV. The epidemic burden in developing countries is dramatic. Ninety-five percent of the world's HIV-infected women are living in developing countries. In industrialized countries, antiretroviral treatment of pregnant women and newborns with azidothymidine (AZT, ACTG 076 regimen) and discouraging breast feeding by HIV-infected mothers are effectively reducing MCT of HIV. However, there are three major obstacles to the systematic application of these strategies in developing countries: (a) difficulties in implementing the complex AZT administration and its corollary the avoidance of breast feeding; (b) the complexity of the logistics of the ACTG 076 regimen; (c) cost. Indeed, in developing countries the socioeconomic situation of the populations are precarious and health structures and services are underdeveloped. In addition, the anxiety and the reluctance of general population in the face of the HIV problem and the high prevalence of maternal anemia reduce the acceptability and safety of AZT treatment for pregnant women in developing regions. Only interventions that are applicable, acceptable, safe, affordable, of low cost and integrated into health system will be able to reduce HIV MCT. We now know that MCT occurs mostly during the perinatal period and the maternal viral load in blood, in cervical secretions and in breast milk appears to be the main determinant of transmission. Maternal vitamin A deficiency may also favor MCT of HIV. It is however possible that this association is confounded by the relationship between advanced maternal HIV disease (a known risk factor for transmission) and vitamin A deficiency. In spite of these uncertainties concerning determinants of MCT of HIV, several interventions have been designed. The first involves treating the mother with antiretroviral drugs for the perinatal period. The second is vaginal disinfection by application of virucidal antiseptics during the perinatal period. The third is to give vitamin A supplements to pregnant women and children. Finally, passive immunotherapy with anti-HIV antibodies applied to pregnant women and/or new born, may be beneficial. The feasibility, safety and efficacy of these potential interventions have not yet been demonstrated in developing countries. In view of the dramatic spread of HIV infection in these countries, the evaluation of these interventions is of utmost priority. These trials are necessary because of the public health emergency but should be performed in strict respect of human rights and medical ethics.

Anemia↗

PubMed1997

Impact of body size on women's military obstacle course performance.

The United States Military Academy uses an Indoor Obstacle Course Test (IOCT) to assess military-relevant physical fitness. There are both anaerobic and aerobic fitness components to this test. Recent attention has been focused on the apparent difficulty of heavier female cadets to succeed on the IOCT. The purpose of this study was to use allometric scaling to examine the effects of body weight (BW), fat-free mass (FFM), percent body fat (%BF), and fat mass (FM) on IOCT performance for female cadets. The sample included 38 female cadets who successfully completed the IOCT. Performance was defined by the time, T, to complete the entire course. FFM was determined via a three-site skinfold test. Allometric modeling was used to determine the exponent in the following index: T*BW2 such that the independent contributions of body size are partialled out. This analysis was used for all four independent variables simply by substituting BW with the other independent variables. The following exponents were found to be significant (p < 0.05): 0.45 +/- 0.13 for %BF and 0.24 +/- 0.12 for FM indicating that these independent variables play a significant role in female performance on the IOCT. For example, if a female cadet could decrease her %BF from 20% to 18%, which would be decrement of ten percent, then her estimated decrease in IOCT time is 4%. In addition, a trend (p = 0.06) was found for FFM meaning that as FFM increases, T decreases. We conclude that, among USMA female cadets, small decreases in %BF may be significantly advantageous to IOCT performance.

Adult↗

PubMed1998

[Lower extremity deformities as an obstacle in rehabilitation of meningomyelocele patients--pathogenesis and principles of treatment].

The fate of 89 patients with meningomyelocele operated at the Institute of Orthopedics and Rehabilitation in Poznań between 1970 and 1989 due to paretic deformities of lower extremities has been traced by the authors. Deformities prevented nursing, standing or ambulating; their type and results of treatment have been related to the level of neurosegmental lesion. Modified Sharrard's classification served to group the patients. The level of lesion established during lower extremities muscles testing has been verified after neurological examination supplemented with electrophysiological tests: sensory response within L3-S2 dermatomes, afferent conduction velocity of the peroneal nerve and selected muscles of lower extremity electromyogram. Deformities due to inadequate nursing (hip and knee contractures and equinus foot) were the main obstacle in the rehabilitation in patients with spinal Th12-L2 lesion. In patients with L3-L5 lesion hip contractures were accompanied by dislocation or subluxation of the hip due to muscular imbalance. Knee contracture was less frequent in this group and foot deformities were diverse. Surgical correction of paretic deformity of the hip was the last stage of management designed to promote rehabilitation, following previous foot and knee surgery. In patients with Th12-L2 lesion recurrence of contractures made standing and walking impossible. In patients with L3-L5 neurosegmental lesion surgery for paretic dislocation or subluxation of the hip inclusive of open reduction, varus-derotation osteotomy of the proximal femur, transiliac osteotomy and iliopsoas transfer to the greater trochanter according to Mustard resulted in stable hip. Seventy percent of patients with L3-L4 lesion and all patients with L5 lesion profited from hip surgery with reduced orthotic use and effective gait.

Adolescent↗

PubMed1998

[Epidemiologic studies among foreign immigrants in Germany--rational and obstacles].

About 7.2 million foreign nationals are living in Germany. Only few epidemiological studies have assessed their health status, unlike in other countries with large migrant populations. Hence, it is not known whether foreigners in Germany experience special health risks and whether there is a need for specific public health interventions. The size of the group (9% of the total population) and their increasing length of stay further emphasise the need for epidemiological research on migrants. In this article we describe the obstacles for such studies in Germany: difficulties in characterising the group of interest; problems of availability and accessibility of data sources; and aspects of data protection. Minor changes in mortality statistics and improved access to existing data sources within the limits of data protection would improve research opportunities.

Data Collection↗

PubMed1998

Obstacles to condom use: the combination of other forms of birth control and short-term monogamy.

Two hundred thirty-seven college students involved in heterosexual relationships were surveyed to determine the effects of relationship type and use of forms of contraception other than condoms on condom use. Findings indicated that in the context of a short-term, monogamous relationship, the use of another form of birth control was associated with decreased condom use. In addition, 20% of the participants reported that they had wanted to use a condom for disease prevention on at least one occasion but had decided not to do so because they were using another form of contraception. Implications for preventive health are discussed.

Adolescent↗