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PubMed2005

Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution?

This paper examines the policy options for the regulation of dual job holding by medical professionals in highly resource-constrained settings. Such activity is generally driven by a lack of resources in the public sector and low pay, and has been associated with the unauthorized use of public resources and corruption. It is also typically poorly regulated; regulations are either lacking, or when they exist, are vague or poorly implemented because of low regulatory capacity. This paper draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. The approach taken in highlighting these broader social objectives seeks to avoid the value judgements regarding dual working and some of its associated forms of behaviour that have tended to characterize previous analyses. Dual practice is viewed as a possible system solution to issues such as limited public sector resources (and incomes), low regulatory capacity and the interplay between market forces and human resources. This paper therefore offers some support for policies that allow for the official recognition of such activity and embrace a degree of professional self-regulation. In providing clearer policy guidance, future research in this area needs to adopt a more evaluative approach than that which has been used to date.

Career Mobility↗
PubMed2002

Utility of captopril renal scans for detecting renal artery stenosis.

BACKGROUND: Captopril renal scanning (CRS) is commonly recommended as a noninvasive method for detecting renal artery stenosis (RAS), based on performance characteristics determined in research settings. Scant data are available, however, regarding the utility of CRS in clinical practice. METHODS: We evaluated the performance characteristics (sensitivity, specificity, and predictive values) of CRS in a consecutive series of 90 patients who underwent both CRS and renal arteriography within a 6-month period (January 1, 1991, through December 31, 1995) at a university hospital. RESULTS: Among 86 eligible patients (and 169 kidneys), the prevalence of RAS was 43%. The sensitivity of CRS was 74% (95% confidence interval [CI], 62%-83%); the specificity was 59% (95% CI, 49%-69%); the positive predictive value was 58% (95% CI, 47%-68%); and the negative predictive value was 75% (95% CI, 64%-84%). Also, there was evidence of spectrum bias, because the sensitivity and specificity (as well as the positive and negative predictive values) were different for groups with and without vascular disease. CONCLUSIONS: The results of CRS were substantially worse in a clinical practice setting than previously reported in research settings, despite a similar prevalence of RAS. Captopril renal scanning should not be used as an initial screening test for diagnosing RAS, even among patients with high clinical likelihood of disease.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

Visual outcomes of cataract surgery in the United States, Canada, Denmark, and Spain. Report From the International Cataract Surgery Outcomes Study.

OBJECTIVE: To compare visual outcomes obtained following cataract surgery in 4 sites in North America and Europe where considerable differences in the organization of care and patterns of clinical practice have been previously described. METHODS: Patients scheduled for first eye-cataract surgery and aged 50 years or older were enrolled consecutively in a prospective multicenter study that collected clinical and patient interview data preoperatively and postoperatively. From the United States, 772 patients were enrolled; from the Province of Manitoba (Canada), 159; from Denmark, 291; and from the City of Barcelona (Spain), 200. Preoperative and 4-month postoperative visual acuity was obtained for 92% of the patients (n = 1291). RESULTS: The mean 4-month postoperative visual acuity of eyes operated on varied significantly across the 4 sites (P < .001) and had the following Snellen decimal fraction measurements: 0.49 in Barcelona, 0.65 in Denmark, 0.66 in Manitoba, and 0.74 in the United States. However, while crude visual acuity outcome figures varied significantly, no significant difference was observed across the 4 sites regarding the risk of poorer visual outcome after controlling for differences in age, preoperative visual acuity, and general health status for patients with no ocular comorbidity. Older age, poorer preoperative visual acuity, poorer preoperative general health status, and coexisting ocular comorbidity were predictors of a poorer visual outcome. CONCLUSION: A previously identified variation in treatment modalities across the 4 sites did not seem to affect patients' visual acuity outcomes.

Aged↗
PubMed2000

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.

CONTEXT: Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. OBJECTIVE: To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. DESIGN: Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. SETTING: Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. PATIENTS: Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). MAIN OUTCOME MEASURES: Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. RESULTS: No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). CONCLUSIONS: In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

Adult↗
PubMed2001

Basic teaching in microsurgery.

We summarize our 15 years of educational experience in the field of teaching microsurgery. The students can be divided into three groups: (1) medical students, (2) researchers, (3) medical doctors and specialists. Characteristics of our method include the following: activity, synchronism, video-assistance, self-controlling, individualization, analysis. The Furka microsurgical educational method, named after one of the authors, is 20 hours long (five 4-hour sessions). The first lesson allows students to become acquainted with the microsurgical instruments. The next lesson consists of learning the probe of layer-feeling. The third lesson is to learn how to produce stitches under the microscope. The fourth lesson includes arterial anastomosis preparation on fresh arterial pieces of animal origin. The fifth lesson means a quality change from previous classes, as practice is performed on living animals, generally rats. The teaching of microsurgical basics requires both patience and empathy. The teaching process is most successful if one teacher deals with a maximum of two students.

Animals↗
PubMedDate not supplied

Health practices of adults with elder care responsibilities.

BACKGROUND: This study examined health-risk behaviors and preventive health care activities among caregivers for older adults. METHODS: Survey questionnaires regarding health practices were completed by 272 caregivers and 917 noncaregivers selected through a stratified random sample of persons age 50 or older who were members of the Kaiser Foundation Health Plan in Northern California. RESULTS: Controlling for age, gender, race, education, marital status, and income level, caregivers were more likely than noncaregivers to eat breakfast daily, get flu shots, and receive pneumonia vaccines. Caregivers and noncaregivers did not differ significantly with regard to any of 10 other health practices or to the total number of positive health behaviors. Poorer health practices were associated with nonwhite racial identification, low income level, part-time employment, and health limitations. CONCLUSIONS: These findings suggest that, at least for caregivers who have access to the extensive health promotion resources of a large health maintenance organization, caregiving responsibilities may not always have the deleterious impact on health and health practices that had previously been assumed.

Aged↗
PubMed2002

Characterization of the LOAEL-to-NOAEL uncertainty factor for mild adverse effects from acute inhalation exposures.

This analysis was undertaken to reduce uncertainty in acute inhalation risk assessment for mild acute effects. Applying uncertainty factors (UFs) to the no-observed-adverse-effect level (NOAEL) is the primary approach used in threshold-based risk assessments. When a NOAEL is unavailable, a UF of 10 is often applied to a lowest-observed-adverse-effect level (LOAEL) to estimate the NOAEL. We evaluated the LOAEL-to-NOAEL relationship for mild acute inhalation toxicity for 215 data sets for 36 hazardous air pollutants. The LOAEL-to-NOAEL ratios were 2.0, 5.0, 6.3, and 10.0 for the 50th, 90th, 95th, and 99 th percentile, respectively. The 90% confidence interval for the 95th percentile was 5.0-7.5. Consequently, based on previous dose placement practice, the LOAEL-to-NOAEL UF of 6 would be protective for 95% of the responses, and a value of 10 would be protective of 99% of the responses. The ratio values were not associated with the size of the experimental group. There was little variability among species, particularly at the median. This analysis is reflective only of mild acute inhalation toxicity. For other exposure routes, exposure durations, or more severe toxicity, the distributions are likely to be different.

Air Pollutants↗
PubMed1991

Plethysmography in the assessment and treatment of sexual deviance: an overview.

Theoretical and practical implications of previous research on plethysmography in the assessment and modification of sexual preferences has been limited by insufficient attention to definitional and procedural issues and sample heterogeneity. This paper reviews current theory and research on the use of the penile plethysmograph to diagnose or predict sexual deviance and to monitor therapeutic change in the modification of sexual preferences. Phallometric tests are discussed in terms of the basic components of the measurement technique, evidence of technical adequacy, and general principles underlying their use. The review points to a need to guard against false expectations and erroneous conclusions about sexual deviance based on this measurement technique. A case is made for closer attention to previously untested working assumptions and issues of definition, etiology, and measurement. Directions for future research are proposed.

Humans↗
PubMed2006

Relationship between low back pain, disability, MR imaging findings and health care provider.

OBJECTIVE: To determine the association between the self-report of pain and disability and findings on lumbar MR images, and to compare two different health care providers in Spanish patients with low back pain (LBP). DESIGN: Cross-sectional MATERIAL AND METHODS: A total of 278 patients, 137 men and 141 women aged 44+/-14 years submitted with low back pain (LBP) were studied. One hundred and nine patients were from the National Health System (NHS) and 169 from private practice. Patients with previous discitis, surgery, neoplasm or traumatic episodes were excluded. Every patient completed a disability questionnaire with six core items, providing a score of disability from 2 to 28. All patients had sagittal spin-echo T1 and turbo spin-echo T2, axial proton-density and MR myelography weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30. RESULTS: Patients with a combination of LBP and sciatica showed the highest levels of disability (p=0.002). MR imaging scores only correlated with pain interference with normal work (p=0.04), but not with other disability questions. Patients from the NHS showed greater disability scores than private ones (p=0.001) and higher MR imaging scores (p=0.01). CONCLUSION: In patients with LBP, MR imaging only correlates with pain interference with work but not with other disability questions. Differences are found between private and NHS patients, the latter being more physically affected.

Adult↗
PubMed2000

Forecasting of the flowering time for wild species observed at Guidonia, central Italy.

It is well known that forecasting the flowering time of wild vegetation is useful for various sectors of human activity, particularly for all agricultural practices. Therefore, continuing previous work by Cenci et al., we will present here three new phenoclimatic models of the flowering time for a set of wild species, based on an original data sample of flowering dates for more than 500 species, observed at Guidonia (42 degrees N in central Italy) by Montelucci in the period 1960-1982. However, on applying the bootstrap technique to each species sample to check its basic statistical parameters, we found only about 200 to have data samples with an approximately Gaussian distribution. Eventually only 57 species (subdivided into eight monthly subsets from February to September) were used to formulate the models satisfactorily. The flowering date (represented by the z variable), is expressed in terms of two variables x and y by a nonlinear equation of the form z=axbeta+gammay. The x variable represents either the degree-day sum (in model 1), or the daily-maximum-temperature sum (in model 2), or the daily-global-insolation sum (in model 3), while y for all three models corresponds to the rainy-day sum. Note that all summations involved in the computation of the variables x and y take place over a certain period of time (preceding the flowering phase), which is a parameter to be determined by the fitting procedure. This parameter, together with the threshold temperature (needed to compute the degree-days in model 1), represents the two implicit parameters of the process, thus the total number of parameters (including these last two) becomes respectively, five for model 1, and four for the other two models. The preliminary results of this work were reported at the XVI International Botanical Congress (1-7 August 1999, St. Louis, Missouri USA).

Agriculture↗
PubMed2002

The case for laparoscopic common bile duct exploration.

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.

Cholangiography↗
PubMed2006

Neonatal imitation in chimpanzees (Pan troglodytes) tested with two paradigms.

Primate species differ in their imitative performance, perhaps reflecting differences in imitative capacity. The developmentally earliest form of imitation in humans, neonatal imitation, occurs in early interactions with social partners, and may be a more accurate index of innate capacity than imitation of actions on objects, which requires more cognitive ability. This study assessed imitative capacity in five neonatal chimpanzees, within a narrow age range (7-15 days of age), by testing responses to facial and vocal actions with two different test paradigms (structured and communicative). Imitation of mouth opening was found in both paradigms. In the communicative paradigm, significant agreement was found between infant actions and demonstrations. Additionally, chimpanzees matched the sequence of three actions of the TC model, but only on the second demonstration. Newborn chimpanzees matched more modeled actions in the communicative test than in the structured paradigm. These performances of chimpanzees, at birth, are in agreement with the literature, supporting a conclusion that imitative capacity is not unique to the human species. Developmental histories must be more fully considered in the cross-species study of imitation, as there is a greater degree of innate imitative capacity than previously known. Socialization practices interact with innate and developing competencies to determine the outcome of imitation tests later in life.

Animal Communication↗
PubMed1992

Complex angioplasty: a surgeon's perspective.

Surgeons commonly have reacted with skepticism to the introduction of catheter-based interventional approaches to treating coronary artery disease, prompted apparently, by a desire to protect what had been exclusively their turf. Reasonable surgeons now largely accept the concept of nonoperative mechanical treatment of coronary heart disease, and their constructive criticisms regarding amelioration of coronary anatomy without thoracotomy remains valuable. The value of catheter-based techniques compared with operative or noninterventional treatment has not been defined in many clinical settings. The complexity of evaluating these rival technologies increases as the complexity of cases progresses from simple 1-vessel disease to more extensive coronary artery disease. Ongoing randomized trials may help define indications for these procedures, but patients entering these trials represent a highly select subset. Therefore, applications to broader patient populations will likely require analysis of observational data. Newer catheter-based technologies introduce modes of injury to the coronary arterial system that have not been encountered previously in medical practice. As technologies evolve, decisions about the need for operative intervention become increasingly complex. In the many clinical settings resulting from efforts to improve angioplasty, optimal patient care occurs in environments with good communication and cooperation between all physicians involved in interventional treatment of coronary artery disease.

Angioplasty, Balloon, Coronary↗
PubMed1983

Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations.

Numerous previous studies of nonspecific vaginitis have yielded contradictory results regarding its cause and clinical manifestations, due to a lack of uniform case definition and laboratory methods. We studied 397 consecutive unselected female university students and applied sets of well defined criteria to distinguish nonspecific vaginitis from other forms of vaginitis and from normal findings. Using such criteria, we diagnosed nonspecific vaginitis in up to 25 percent of our study population; asymptomatic disease was recognized in more than 50 percent of those with nonspecific vaginitis. A clinical diagnosis of nonspecific vaginitis, based on simple office procedures, was correlated with both the presence and the concentration of Gardnerella vaginalis (Hemophilus vaginalis) in vaginal discharge, and with characteristic biochemical findings in vaginal discharge. Nonspecific vaginitis was also correlated with a history of sexual activity, a history of previous trichomoniasis, current use of nonbarrier contraceptive methods, and, particularly, use of an intrauterine device. G. vaginalis was isolated from 51.3 percent of the total population using a highly selective medium that detected the organism in lower concentration in vaginal discharge than did previously used media. Practical diagnostic criteria for standard clinical use are proposed. Application of such criteria should assist in clinical management of nonspecific vaginitis and in further study of the microbiologic and biochemical correlates and the pathogenesis of this mild but quite prevalent disease.

Adult↗
PubMed1985

A mathematical theory of running, based on the first law of thermodynamics, and its application to the performance of world-class athletes.

Following a survey of existing mathematical models of running, a new analysis is developed, based on the first law of thermodynamics. The method properly accounts for each term in the energy balance, and avoids the use of mechanical efficiency factors. A relationship is derived between race distance and the time taken to run that distance. An excellent correlation of results from recent Olympic Games is established for events over distances from 100 m to 10,000 m. The velocity-time relationship for a sprinter running 100 m at maximum available power is obtained by numerical integration of the power equation. It is shown that the peak velocity is achieved in the middle stages of the race, a result which is consistent with practice, but which previous calculations based on Newton's laws have failed to predict. Further applications of the analysis are indicated.

Biomechanical Phenomena↗
PubMed1993

Time-dependent variability in repeated measurements of cholesterol levels: clinical implications for risk misclassification and intervention monitoring.

Intraindividual variability (IIV) in total cholesterol levels based on measurements taken 1 week apart is compared with an estimate based on measurements taken 2 years apart. Single-subject 95% confidence intervals around the mean of two repeated measurements were Xi +/- 21 and +/- 28 mg/dl, respectively, and Xi +/- 30 and +/- 40 mg/dl for a single measurement. Comparing these results with published estimates over varying time intervals shows a trend of decreasing IIV with shorter intervals, suggesting that confidence interval widths based on short-term repeated measurements and those based on longer-term repeated measurements may differ more than previously assumed. The practical consequences are that: (1) the level of misclassification inherent in the National Cholesterol Education Program (NCEP) guidelines may be less than had been estimated; and (2) reliable cholesterol reductions resulting from dietary or other interventions may be somewhat easier to detect. These findings have implications for the cost-effectiveness of cholesterol screening strategies and interventions to reduce cholesterol.

Adult↗
PubMed1995

Molecular design and biological activity of potent and selective protein kinase inhibitors related to balanol.

BACKGROUND: The protein kinase C (PKC) family of serine/threonine-specific protein kinases is involved in many cellular processes, and the unregulated activation of PKC has been implicated in carcinogenesis. PKC inhibitors thus have significant potential as chemotherapeutic agents. Recently, the fungal metabolite balanol was shown to be an exceptionally potent inhibitor of PKC. We previously developed a practical and efficient total synthesis of balanol. We set out to use this synthetic molecule, and several synthetic analogs, to probe the mechanism of PKC inhibition and to determine the effect of balanol on the activity of other protein kinases. RESULTS: As well as inhibiting PKC, balanol is a potent inhibitor of cyclic AMP-dependent protein kinase (PKA), another protein serine/threonine kinase. Balanol does not, however, inhibit the Src or epidermal growth factor receptor protein tyrosine kinases. The inhibition of both PKC and PKA by balanol can be overcome by high concentrations of ATP, and molecular modeling studies suggest that balanol may function as an ATP structural analog. Although balanol discriminates rather poorly between PKC and PKA, only minor modifications to its molecular structure are required to furnish compounds that are highly specific inhibitors of PKA. CONCLUSIONS: A number of balanol analogs have been designed and synthesized that, unlike balanol itself, exhibit dramatic selectivity between PKA and PKC. Thus, despite the substantial homology between the catalytic domains of PKA and PKC, there is enough difference to allow for the development of potent and selective inhibitors acting in this region. These inhibitors should be useful tools for analyzing signal transduction pathways and may also aid in the development of drugs with significant therapeutic potential.

Adenosine Triphosphate↗
PubMed2004

A tool to assess barriers to adherence to hand hygiene guideline.

This Brief Report presents results of preliminary testing of a tool, "Attitudes Regarding Practice Guidelines," adapted from previous work by Cabana et al to examine barriers to adherence to practice guidelines. In a small sample of 21 clinicians (10 infectious disease physicians and 11 clinical nurses), the test-retest reliability was.86 and Chronbach alpha was.80, indicating acceptable levels of stability. It is recommended that the instrument undergo further testing and adaptation as a measure of potential barriers to adherence to practice guidelines in general, and to the new Hand Hygiene Guideline for Healthcare Settings specifically.

Attitude of Health Personnel↗