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When social workers and physicians collaborate: positive and negative interdisciplinary experiences.

Interdisciplinary collaboration is becoming increasingly important as the current complexity and cost of health care require an efficient and well-coordinated service delivery system. To understand the factors contributing to positive and negative collaboration, 53 social workers and 50 physicians in 12 hospital settings were interviewed about their best and worst experiences collaborating on a case. Thirty precoded items were classified into three constructs that reflect aspects of collaboration related to the case, to interaction between collaborators, and to the competence of the collaborator. Differences between the two professions were greatest on the interactional factors, with social workers valuing them much more than physicians did. Communication appeared to be the only intrinsic or universal aspect of collaboration equally important to both groups in both types of cases. Implications for social work practice and leadership are discussed.

Attitude of Health Personnel↗

Implantology for general practitioners.

The following is a case report involving the use of implants designed for use by general dental practitioners. Implantology has advanced to the point that it can no longer be ignored by anyone. Most of us as general dentists avoid implantology, owing to the inherent complexity and cost current systems. Changes must be made to implant designs which will allow general dentists to accomplish all aspects of conservative implant treatment. The implants employed in this case permitted prosthetic treatment similar to that performed on endodontically treated teeth, an approach most general dentists understand.

Bicuspid↗

[Angina pectoris. The extent of the problem].

Angina pectoris is analysed according to the principal data of its social repercussion: frequency, gravity, chronicity, diagnostic and treatment complexity, treatment costs and genetic factor extension. Some data of the national literature defining the dimension of the problem are given and a comparative study with other diseases and other countries is made. In conclusion, the need to develop epidemiological studies of adequate dimension is supported, mostly to better define frequency of the disease (prevalence and incidence) since the hospital and the mortality data are not enough. However, from the available data, it is expected that the prevalence of ischemic heart disease, of which the angina is a frequent clinical manifestation, will increase as well as the economic costs. In fact, the costs will be the consequence of scientific and technological development and of the increasing search for health by the population can services.

Angina Pectoris↗

[One stage operation for sternal turnover with preserved rectus muscle pedicles and aortic root replacement associated with Marfan's syndrome].

A 40-year-old man with Marfan's syndrome had annulo aortic ectasia with Sellers grade 4 aortic valve regurgitation and Wada grade 3 pectus excavatum. Simultaneous operation was successfully performed by aortic valve composite graft insertion and sternal turnover with the rectus muscle pedicles. Following a midline skin incision, the cost-sterno complex (plastron) was dissected together with the bilateral rectus muscle pedicles, and the sternum was divided transversely through the second intercostal space. The plastron with muscle pedicles was retracted away from the anterior chest toward the abdomen and was covered by the moistened sternal bag made of polyethylene to prevent dryness and contamination during the composite graft insertion. The aortic root was replaced with a composite graft consisting of a 25 mm SJM valve and a 26 mm Hemashield graft. A short interposed 10 mm Hemashield graft was inserted between the ostia of the left coronary artery and the composite graft. The right coronary artery was reimplanted in the aortic conduit using the button technique with a doughnut pledget. This one stage method offered excellent operative exposure and enabled us to prevent possible necrosis of the sternum, infection of the mediastinal sinus, and postoperative cardiac failure resulting from chest wall compression. In this procedure, active usage of the rapid autologous transfusion system effectively reduced the total amount of blood transfusion.

Adult↗

Sample collection, processing and storage.

We review issues related to the inclusion of biospecimens in epidemiological studies. Technical advances and the revolution in molecular biology have rendered the use of biomarkers increasingly feasible in epidemiological investigations, however the cost and complexity require interdisciplinary expertise and careful attention to methodological detail in order to ensure validity. The widespread banking of biospecimens for long-term (cohort) studies requires special attention to be paid to these issues. Blood, urine and tumour tissue are in common use in medicine and at least some aspects of sample handling derives directly from this clinical experience, although special considerations apply in the epidemiological setting. An increasingly broad array of biospecimen types have been studied, including exhaled air, nail clippings, buccal cells, saliva, semen, faeces and breast milk. Relevant issues in the processing, storage, shipping, timing of collection and safety procedures are examined in terms of their potential to distort results. The role of carefully developed quality control protocols is emphasized. In order to take full advantage of the opportunities afforded by the use of biomarkers in epidemiological studies, careful attention to biospecimen processing, the stability of the biomarker and the precautions to be taken during transportation and storage of samples is necessary.

Biomarkers, Tumor↗

[Simultaneous repair for funnel chest and intracardiac lesions in two pediatric patients].

Two successful cases underwent simultaneous repair for funnel chest using sternal turnover with rectus abdominal flap and intracardiac lesions were reported. A 7-year-old female (case 1) was diagnosed with funnel chest and annulo-aortic ectasia due to Marfan's syndrome. Second patient was a 12-year-old male (case 2) with funnel chest and ventricular septal defect (VSD). Both patients underwent sternal turnover and intracardiac repair (case 1: Bentall's operation, case 2: patch closure of VSD), simultaneously. Removing the cost-sterno complex before cardiac operation allowed an excellent surgical exposure. Bleeding was minimum, especially no homologous blood transfusion was needed in case 2. Simultaneous surgery consisted of intracardiac repair and sternal turnover is recommended even for pediatric patients.

Aortic Valve Insufficiency↗

[Cell therapy: from experimentation to innovative medical practice].

Like all new and emerging technologies, cell therapy has raised many hopes for the treatment of some severe diseases. However, its development needs first a clear ethical and legal framework. Because of the complexity and cost of these therapies, development has to be focused on fields where clinical benefits appear greater and where therapeutic alternatives are limited. Since 28 May, 1996 France has had a law (No. 96-452) which defines the 'biological products for therapeutic use' and therefore cell therapy. Many different therapeutic domains are concerned, depending on cell type. The level of development already reached and the number of patients concerned are quite variable. The grafting of hematopoietic stem cells and of expanded keratinocytes, which concerns in France 2500 and 100 patients per year respectively, are well characterized. The clinical trial of dendritic cells for vaccination is just starting but could represent a very large field of application with more than 10,000 patients per year. The grafting of hepatocytes, and the production of antiviral CTL and encapsulated cells (Langerhans islets of allo- or xenogenic origin), nerve cells, and myocytes are still at an early stage of development. Whatever the field, before entering clinical trials, a clear scientific and medical rationale must exist. The efficacy and security of the proposed treatment should be established on relevant models. Cell processing protocols must be well characterized and reproducibility proven with quality controls in place and the cell processing facilities approved by the relevant authorities. Partnership with industry could take many different forms. It should speed up development by providing access to reagents, growth factor of clinical grade, devices, cell processing technologies, etc., without preventing investigators from conducting their trial as planned.

Animals↗

[Diagnostic and therapeutic approach to male sterility].

The new techniques of medically assisted procreation allow to approach most of the male infertilities. Their complexity and cost call for a precise diagnosis prior to treatment initiation and a multidisciplinary investigation of the sterile couple is mandatory. We demonstrate the urological side of these investigations.

Diagnosis, Differential↗

Administration of zidovudine during late pregnancy and delivery to prevent perinatal HIV transmission--Thailand, 1996-1998.

Worldwide, approximately 500,000 infants are perinatally infected with human immunodeficiency virus (HIV) each year, most of whom are born in developing countries. In 1994, a clinical trial in the United States and France demonstrated that zidovudine (ZDV) administered orally five times a day to HIV-infected pregnant women starting at 14-34 weeks' gestation, intravenously during labor, and orally to their newborns for 6 weeks reduced the risk for perinatal HIV transmission by two thirds. In 1994, this regimen was recommended as standard care in the United States; however, because of its complexity and cost, this regimen has not been implemented in most developing countries, and no other intervention had been efficacious in reducing perinatal HIV transmission. In 1996, the Ministry of Public Health of Thailand and Mahidol University, in collaboration with CDC, initiated a randomized, placebo-controlled trial of a simpler and less expensive regimen of ZDV to prevent perinatal HIV transmission. This report describes preliminary trial results, which indicate that a short-term antenatal regimen of ZDV reduced the risk for perinatal HIV transmission by approximately half.

Anti-HIV Agents↗

[Activity and morbimortality of coronary surgery in Spain].

The goal of the study is to describe the current knowledge about coronary artery by-pass surgery in Spain related to activity, institutions, and clinical outcomes. A search in the MEDLINE (1982-97) and IME (1976-97) databases and manual search in medical journals, official publications of scientific societies was performed. References whose authors or institutions in charge were located in Spain, and including data on activity, mortality and morbidity of coronary artery bypass surgery alone or in combination with other procedures. In 1995, 7,936 coronary procedures were carried out (alone or in combination) in 51 Spanish centres, representing an increase of 123% in those procedures registered and published in 1988. Hospital mortality, according to the Registry of the Spanish Society of Cardiovascular Surgery (1995), was 7.2%. Data from multicenter studies showed, allowing for variations among centres, 8.8% (1975-82) and 8.1% (1994) mortality in isolated coronary revascularization. Other studies refer to the particular experience in a centre, examining either predictive mortality factors or outcomes in specific clinical conditions. Surgical mortality has been only partially analysed in multicentre studies, although several groups refer to the incidence of their own specific complications. There are few multicentre studies assessing morbidity and mortality in coronary artery surgery and some results (quality of life, economical) have been poorly evaluated. An alternative to be considered is the creation of an advisory commission aimed at establishing health care standards and at supporting an information system on the patients characteristics, techniques applied, and results obtained in the provision of cardiological procedures that, due to their invasiveness, complexity and cost, can be considered as tertiary cardiological care.

Coronary Artery Bypass↗

Implementing a low-cost computer-based patient record: a controlled vocabulary reduces data base design complexity.

In order to build a computer-based patient record (CPR) system suitable for use in solo and small group practice settings it is necessary to use development methods that minimize cost. Design complexity is a major source of high cost. Reducing complexity should result in lower development, deployment and maintenance costs as well as higher reliability. We have developed a simplified relational model and have used that model, in conjunction with a controlled vocabulary, to implement a CPR that can capture and store patient examinations and other forms of clinical notes as well as laboratory and other test results. The information can be viewed in a familiar document format and it can accessed for other types of processing using standard Structured Query Language (SQL) techniques. The database, as implemented, uses inexpensive components resulting in a system that is not prohibitively expensive for solo practitioners and small groups. In addition the architecture is scaleable and can accommodate very large numbers of patients and practitioners.

Computer Systems↗

Clinical comparison of acute single to dual chamber pacing in chronotropically incompetent patients with left ventricular dysfunction.

Dual chamber, rate responsive (DDDR) pacing is felt to be superior to ventricular, rate responsive (VVIR) pacing since it more closely mimics the normal electrical and hemodynamic activity of the heart. This reasoning has been used to justify the higher initial costs and increased complexity of dual chamber system. This study was designed to determine if objective criteria could be identified during acute testing justify implanting a dual chamber instead of a single chamber system in patients with left ventricular dysfunction. Eight patients with DDDR pacemakers (implanted for chronotropic incompetence) and left ventricular dysfunction underwent exercise radionuclide angiography and graded exercise treadmill testing. Each patient performed the tests in the single (VVIR) and dual (DDDR) chamber modes in a randomized, blinded fashion. We found that objective parameters such as ejection fraction (31% +/- 13% vs 31% +/- 10%), exercise tolerance (6.1 +/- 2.7 min vs 6.3 +/- 2.9 min), oxygen consumption (VO2) (941 +/- 286 mL/min vs 994 +/- 314 mL/min), carbon dioxide production (VCO2) (995 +/- 332 mL/min vs 1054 +/- 356 mL/min), and maximum attainable workload (43 +/- 24 W vs 46 +/- 22 W) did not differ between the single and dual chamber pacing modes. These findings suggest that in the acute setting, the additional cost and complexity of dual chamber, rate responsive pacing cannot be justified by objective improvements in exercise tolerance in patients with underlying left ventricular dysfunction.

Aged↗

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries.

OBJECTIVES: To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability. SUBJECTS AND SETTING: Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury. METHODS: Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)). RESULTS: Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups. CONCLUSIONS: The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

Activities of Daily Living↗

Medical costs of ambulatory patients with AIDS-related complex (ARC) and/or generalized lymphadenopathy syndrome (GLS) related to HIV infection, 1984-85.

A cost-of-illness study July 1, 1984-June 30, 1985 evaluating 28 patients with AIDS-Related Complex (ARC) and/or Generalized Lymphadenopathy Syndrome (GLS) found the average cost to be $489 per patient per year. None of the ARC or GLS patients in our study was hospitalized during the one year period, and none progressed to AIDS. No AIDS-specific treatment such as AZT was available at the time this study was completed.

AIDS-Related Complex↗

Complex response competition and dopamine blocking: choosing of high cost sucrose solution versus low cost water in rats.

The effect of DA blocking with pimozide on complex response competition involving coupling of cost and benefit was studied with a double-bottle test in lickometer: The competition occurred between two responses; licking of 2% sucrose solution requiring a high effort of standing up and licking of water requiring a low effort of crouching posture. Rats normally chose sucrose over water (76% with vehicle); however, pimozide (0, 0.25, 0.375 and 0.5 mg/kg) diminished licking of the sucrose solution dose-dependently (57% at 0.5 mg/kg) without affecting licking of water. Analysis of lick pattern suggested that this shift in choice was attributable not much to a potential effect of pimozide to hamper motor capability or to reduce rewarding impact of sucrose because (a) the difference in licking profile for sucrose and water remained intact, (b) rats remained fully capable of assuming the standing posture for sustained and efficient licking of sucrose, and (c) the integrity of licking pattern largely remained. Pimozide appeared to selectively affect the behavior that cost more but with higher reward; rats settled with behavior that cost less with lower reward. Rats became less motivated to invest effort for a better reward, a behavior pattern described as "indolent". A more complex view of incentive motivation including coupling of behavioral cost and benefit was presented as a theory to explain the DA mediation of reward-maintained behaviors.

Animals↗

Modeling transport in polymer-electrolyte fuel cells.

In this review, we have examined the different models for polymer-electrolyte fuel cells operating with hydrogen. The major focus has been on transport of the various species within the fuel cell. The different regions of the fuel cell were examined, and their modeling methodologies and equations were elucidated. In particular, the 1-D fuel-cell sandwich was discussed thoroughly because it is the most important part of the fuel-cell assembly. Models that included other effects such as temperature gradients and transport in other directions besides through the fuel-cell sandwich were also discussed. Models were not directly compared to each other; instead they were broken down into their constitutive parts. The reason for this is that validation of the models is usually accomplished by comparison of simulation to experimental polarization data (e.g., Figure 3). However, other data can also be used such as the net flux of water through the membrane. In fitting these data, the models vary not only in their complexity and treatments but also in their number and kind of fitting parameters. This is one reason it is hard to justify one approach over another by just looking at the modeling results. In general, it seems reasonable that the more complex models, which are based on physical arguments and do not contain many fitting parameters, are perhaps closest to reality. Of course, this assumes that they fit the experimental data and observations. This last point has been overlooked in the validation of many models. For example, a model may fit the data very well for certain operating conditions, but if it does not at least predict the correct trend when one of those conditions is changed, then the model is shown to be valid only within a certain operating range. This review has highlighted the important effects that should be modeled. These include two-phase flow of liquid water and gas in the fuel-cell sandwich, a robust membrane model that accounts for the different membrane transport modes, nonisothermal effects, especially in the directions perpendicular to the sandwich, and multidimensional effects such as changing gas composition along the channel, among others. For any model, a balance must be struck between the complexity required to describe the physical reality and the additional costs of such complexity. In other words, while more complex models more accurately describe the physics of the transport processes, they are more computationally costly and may have so many unknown parameters that their results are not as meaningful. Hopefully, this review has shown and broken down for the reader the vast complexities of transport within polymer-electrolyte fuel cells and the various ways they have been and can be modeled.

Journal Article↗