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PubMedDate not supplied

Health care delivery systems: effects on surgical education in Italy.

Since 1989 a national health system (NHS) has been in effect in Italy based on the constitutional principle that health care is a right of all citizens. Until 1992 the NHS had a secondary role in medical education, as the 33 medical schools for postgraduate training are under the control of the Ministry of University. The European Community legislation allowing free movement of M.D.s and specialists between member countries has resulted in standardization of teaching programs and formative curricula in the European Community. Therefore beginning in 1992, every 3 years the Ministry of Health and University establishes the number of specialists that can meet the needs of the NHS and allocates funds to each school for the salary obligations. The actual number of paid residents for surgical specialties is 941 per year (192 for general surgery). Until recently surgical training in Italy was mainly theoretic, as no legislation guaranteed that physicians in training would perform surgery. New legislation, increased exchanges with European hospitals, and improved and loyal cooperation between universities and the NHS will certainly improve the situation in coming years.

Delivery of Health Care↗
PubMed1983

Primary health care provision in terms of community need in South Africa.

In South Africa, early lessons in primary health care were lost to sight and have been rediscovered only recently. Priorities need to be reassessed in order to better allocate resources to community needs. Developing and developed communities require different primary care services. Simple and effective epidemiological methods should be used to gather information required for planning and evaluation of services. In developing communities, where there is a shortage of doctors, trained nurses operate local clinics with the help of community workers. Community participation and the cooperation of the traditional healers are necessary. Appropriate training of personnel for an effective role in public health care is essential.

Community Health Services↗
PubMed1997

When will managed care come to anesthesia?

Managed care has begun to reshape many areas of health care practice, but anesthesia is not yet among them. The economics of anesthesia care are characterized by widespread inefficiency in the allocation of labor, and a unique market structure that poses special challenges to managed care influence. The potential for savings is great, perhaps as much as a one percent decrease in commercial health costs. But these savings can only be realized if managed care organizations are able to restructure the incentives facing anesthesia professionals to promote innovation, cooperation, and shared benefits of efficiency improvements.

American Hospital Association↗
PubMed2006

Justified commitments? Considering resource allocation and fairness in Medecins sans Frontieres-Holland.

Non-governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non-governmental organizations (NGOs) play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self-mandating and self-regulating. What is needed in terms of accountability is some means by which all the relevant stakeholders can have their interests represented and considered. An ideally accountable decision-making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate-based justifications and advocacy-based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long-term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole.

Community-Institutional Relations↗
PubMed1987

Interferons in the treatment of multiple myeloma.

Recently, recombinant DNA methods have been successfully applied to interferon production, making adequate quantities available for both in vitro and in vivo testing. Although interferons are in the class of biologic response modifiers, they do have some direct cytotoxic effects on human tumor cells that can be quantitated in vitro with the colony-forming assay. In the clonogenic assay, RPMI-8226 myeloma cells were tested with interferon alfa-2b (Intron A, Schering Corp., Kenilworth, NJ), melphalan, cyclophosphamide, and prednisone. With concentrations of interferon alfa-2b as low as 1 U/ml (international antiviral activity), colony number was reduced to less than 30% of the untreated control cultures. Both melphalan and cyclophosphamide showed measurable cytotoxic activity, with the ID50 of melphalan at 0.15 microgram/ml and that of cyclophosphamide at 0.4 microgram/ml. Prednisone had the least cytotoxic effect when tested with these myeloma cells as a single agent. Additive antiproliferative effects were noted with combinations of interferon alfa-2b plus cyclophosphamide and interferon alfa-2b plus prednisone. However, the interferon-melphalan combination showed synergistic effects on tumor colony cell reduction. Even greater cytotoxic activity was seen with the three-drug combination of interferon alfa-2b, melphalan, and prednisone. Clinical trials have shown that interferon alfa-2b may be effective in relapsing and refractory patients with multiple myeloma. Of 38 evaluable patients, a total of seven responded to treatment; one patient had a complete response, and six had a partial response. Three of the seven responders have continued to respond for over 33 months, with monoclonal proteins approaching undetectable levels. A pilot study of the feasibility of combining interferon alfa-2b with melphalan and prednisone in previously untreated patients with multiple myeloma has been completed. It is concluded that interferon alfa-2b, in dosages not exceeding 2.0 X 10(6) IU/m2, can be safely given in combination with melphalan and prednisone, without compromising melphalan dosage. Although response was not the primary objective of the study, an overall response of 75% was achieved using the criteria established by the Chronic Leukemia-Myeloma Task Force.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1989

Serum and testicular testosterone and androgen binding protein profiles following subchronic treatment with carbendazim.

While the general toxicity of the benzimidazole pesticides for mammals is low, one of these compounds, carbendazim (MBC), causes degeneration of testicular tissue and decreases spermatogenic activity at doses well below the LD50 value. A study conducted by S. D. Carter, R. A. Hess, and J. W. Laskey (1987, Biol. Reprod. 37, 709-717) showed that treatment with 400 mg/kg/day MBC resulted in severe seminiferous tubular atrophy and infertility. Since spermatogenesis is an androgen-dependent process, we characterized the effects of MBC (0-400 mg/kg/day) on the endocrine function of the rat testes. Following subchronic (85 day) exposure, serum hormones (TSH, LH, FSH, and Prl) were measured as were androgen binding protein (ABP) and testosterone in testicular fluids (interstitial fluid and seminiferous tubule fluid). In addition, the functional capacity of the Leydig cell to secrete testosterone was assessed in vitro following an hCG challenge. Subchronic treatment with MBC at doses of 50-100 mg/kg/day had no effect on pituitary or testicular hormone concentrations: 200 mg/kg/day elevated the testosterone concentration in the seminiferous tubule fluid and the ABP concentration in both the interstitial fluid and the seminiferous tubule fluid without affecting serum testosterone or ABP concentrations. The 400 mg/kg/day dose resulted in increased concentration of both testosterone and ABP in the interstitial fluid and seminiferous tubule fluid and elevated serum ABP, with no change in serum testosterone. This endocrine profile is consistent with the testicular atrophy and "Sertoli cell-only" syndrome seen in these animals as reported by Gray et al. (1987, Toxicologist 7, 717). We conclude that seminiferous tubule fluid testosterone may be a result of two factors: (1) increased interstitial fluid testosterone concentrations and (2) decreased testosterone outflow from the testis to the general circulation. Also, increased ABP in the interstitial fluid may reflect a change in the relative secretion of ABP into the interstitial fluid and the seminiferous tubules.

Androgen-Binding Protein↗
PubMedDate not supplied

The usefulness of DST in predicting response to antidepressants: a placebo-controlled study.

Seventy-two out-patients, 55 years or older, suffering from major depression were treated with either nortriptyline or phenelzine for seven weeks under placebo-controlled double-blind conditions. The dexamethasone suppression test (DST) was administered at baseline and at weeks 3 and 7 of treatment, and its usefulness in predicting and/or paralleling clinical response was examined. No correlation was found between baseline DST results and treatment response with antidepressants. Of 13 patients whose abnormal baseline DSTs normalized during treatment, six were responders and seven were nonresponders (P = 0.24). However, all (seven) patients whose DSTs persisted to be abnormal throughout the seven weeks did not respond. The authors conclude that the DST has not been shown to have practical value as an indicator of impending recovery from major depression in the elderly, but its failure to normalize may have ominous prognostic significance.

Aged↗
PubMed1987

Radiotherapy with or without misonidazole for patients with stage IIIB or stage IVA squamous cell carcinoma of the uterine cervix: preliminary report of a Radiation Therapy Oncology Group randomized trial.

Between August 1980 and November 1984, 119 patients with FIGO Stage IIIB or IVA squamous cell carcinoma of the uterine cervix were randomized to receive radiation therapy (4600 cGy pelvis plus 1000 cGy parametrial boost) followed by intracavitary or external boost to the primary with or without misonidazole (MISO) (400 mg/m2 daily 2 to 4 hours prior to radiation therapy). Patients in the two treatment groups were evenly distributed with respect to stratification variables including stage, Karnofsky Performance score, and positivity of para-aortic nodes. Eighty-nine percent of patients had Stage IIIB disease and 88% had a Karnofsky score of 80 or better. Seventy-five percent of patients treated with radiation therapy alone and 79% of patients treated with radiation therapy plus MISO received a boost via intracavitary application. Life threatening (Grade 4) complications occurred in 5 patients receiving radiation therapy alone and one patient receiving radiation therapy plus MISO. MISO toxicity (Grade 3) was limited to severe nausea and vomiting in two patients. With 119 evaluable patients and a median follow-up of 33 months, 64% of patients receiving radiation therapy alone are alive at 18 months compared with 54% for patients assigned to radiation therapy plus MISO. The median survival for patients treated with radiation therapy alone and radiation therapy plus MISO was 1.9 years and 1.6 respectively. At this point in the study the difference in survival is inconsistent with the hypothesis of an improvement associated with MISO. There have been 23 deaths among the 49 patients treated with radiation therapy plus MISO who have been followed for at least 18 months compared with 17 deaths in 48 patients treated with radiation therapy alone. The chance of observing this number of deaths with radiation therapy plus MISO if the addition of MISO improves survival by 10 to 20% is 0.003 and less than 0.001, respectively. The addition of MISO to radiation failed to improve survival for these patients. The results cannot be explained by an uncharacteristically high survival on the radiation therapy alone arm or by an imbalance in the distribution of prognostic factors. Local-regional control remains a problem in the management of patients with advanced cervical carcinoma. More effective and less toxic radiosensitizing agents are needed.

Adolescent↗
PubMed2002

Use of GnRH agonist implants for long-term suppression of fertility in extensively managed heifers and cows.

The ability of gonadotrophin releasing hormone (GnRH) agonist implants to suppress ovarian activity and prevent pregnancies, long-term, was examined in heifers and cows maintained under extensive management. At three cattle stations, heifers (2-year-old) and older cows (3- to 16-year-old) were assigned to a control group that received no treatment, or were treated with high-dose (12 mg, Station A) or low-dose (8 mg, Station B and Station C) GnRH agonist implants. The respective numbers of control and GnRH agonist-treated animals (heifers + cows) at each station were: Station A, 20 and 99; Station B, 19 and 89; Station C, 20 and 76. Animals were maintained with 4% bulls and monitored for pregnancy at 2-monthly intervals for approximately 12 months. Pregnancy rates for control heifers and control cows ranged from 60-90% and 80-100%, respectively, depending on the study site. The respective number of animals (heifers + cows) treated with GnRH agonist that conceived, and days to first conception, were: Station A, 9 (9%) and 336 +/- 3 days; Station B, 8 (10%) and 244 +/- 13 days; Station C, 20 (26%) and 231 +/- 3 days. Treatment with high-dose GnRH agonist prevented pregnancies for longer (approximately 300 days) than treatment with low-dose GnRH agonist (approximately 200 days). In the majority of heifers and cows treated with GnRH agonist, ovarian follicular growth was restricted to early antral follicles (2-4mm). The findings indicate that GnRH agonist implants have considerable potential as a practical technology to suppress ovarian activity and control reproduction in female cattle maintained in extensive rangelands environments. The technology also has broader applications in diverse cattle production systems.

Animal Husbandry↗
PubMed2000

Identifying persons with chronic conditions in a managed care setting. A comparison of methods.

PURPOSE: Together, the sophisticated computerized information systems and defined, stable populations within Health Maintenance Organizations (HMOs) can reduce imprecision associated with modeling disease incidence and prevalence. Such data are useful for resource allocation, intervention planning, epidemiological study and surveillance. Identifying all cases of illness within such a defined population is vital to these aims, yet detailed diagnostic information is lacking in many pre-paid plans. In this presentation, diagnostic and prescription data are compared for their ability to assess the treatment prevalence for 28 chronic medical conditions.METHODS: Group Health Cooperative is a mixed model HMO in Western WA state. Automated records for calendar year 1999 were examined for 182,174 commercially insured patients age 20-64. Prescription drug data and International Classification of Disease-9(th) Clinical Modification codes (ICD-9CM) were used to identify 28 chronic medical conditions among patients. Chi square tests were performed to compare results produced by the two methods.RESULTS: The diagnostic method worked best for conditions with no clear pharmacologic treatment. However, the pharmacy-based method better identified patients with chronic illnesses initially diagnosed prior to 1999, and with disorders for which standard diagnostic codes are inconsistently utilized, such as mental health conditions.CONCLUSIONS: While both diagnostic and pharmacy-based methods perform well in identifying a limited set of conditions, each performs poorly under certain circumstances. A hybrid method utilizing both diagnostic and pharmacy data may be more appropriate for an HMO setting. Additional research is needed to develop and refine such a method.

Journal Article↗
PubMed1990

The terminal quality of life and passive or active euthanasia.

The problems presented by the different categories of dying people are briefly discussed from the point of view of terminal quality of life. Euthanasia is used in its broader meaning, including both passive and active aspects. Passive euthanasia (PE) is exercised by withholding advanced or basic life support measures, the commonest form being do not resuscitate orders (DNR). Some data on its application are presented. Active euthanasia (AE), which has been proposed and being applied to a limited extent lately, is criticized as leading the physician and the Society onto risky ground. A position is being taken against it. Decision making, examples of guidelines, legal, philosophical and spiritual considerations are discussed. Wisdom and loving care should be exercised by the physician to assist people in their terminal phases and to alleviate their suffering. That there is not a single answer to the problem is discussed.

Humans↗
PubMed1988

The cardiovascular effects of anticholinergic agents administered during halothane anaesthesia in children.

The cardiovascular effects of anticholinergic agents administered during halothane anaesthesia were studied in 31 children aged 1-12 years undergoing peripheral orthopaedic surgery. Either normal saline, glycopyrrolate (10 micrograms.kg-1) or atropine (20 micrograms.kg-1) was administered in randomized double-blind fashion during the induction of anaesthesia with halothane while the electrocardiogram was continuously recorded. After induction, the children were paralyzed with atracurium, intubated, and ventilated. Anaesthesia was maintained with N2O/O2 and halothane (up to 2.5% inspired). The concentrations of expired CO2 and halothane were measured continuously using mass spectrometry. Sixty-one percent (19/31) of the children developed one or more dysrhythmias. Junctional rhythm occurred in 74% (14/19) of the children with dysrhythmias, developed early during induction (mean +/- s.d. time = 2.29 +/- 2.0 min after commencement of induction), and usually resolved before the administration of the study drug (8/14). All dysrhythmias initially occurred before or during induction and none developed during intubation, during incision, during the maintenance of anaesthesia, or after the administration of anticholinergic agents. The data suggest that: 1) a combination of factors present during halothane induction is highly dysrhythmogenic especially for junctional rhythm; 2) junctional rhythm will resolve spontaneously; 3) the administration of an anticholinergic agent during halothane induction is safe but may be unnecessary in children greater than 1 year of age; and 4) the dysrhythmogenic factors present during induction are attenuated during the maintenance of halothane anaesthesia.

Anesthesia, Inhalation↗
PubMed1986

Oestriol with oestradiol verses oestradiol alone: a comparison of endometrial, symptomatic and psychological effects.

In a prospective, double-blind, randomized, cross-over trial, the effects of oral oestradiol, 2 mg daily, on the endometrial histology, frequency and severity of vaginal bleeding, and the symptomatic and psychological status of postmenopausal women were compared with those of oral oestradiol, 2 mg daily, plus oestriol, 1 mg daily. Both therapies were prescribed for 3 months on a cyclical basis. The addition of oestriol to oestradiol did not modify the endometrial response. The prevalence of proliferative/hyperplastic endometrium (64%: 9 of 14 biopsies) was similar after both treatments and there were no significant differences in either the frequency or heaviness of vaginal bleeding. Both therapies significantly reduced hot flushes, night sweats and vaginal dryness: no significant differences in effect on the symptomatic and psychological status were recorded. The addition of 1 mg of oestriol to 2 mg of oestradiol did not confer any benefit and the value of such an addition is challenged.

Adult↗
PubMed1988

Improvement of long-term survival in extensive small-cell lung cancer.

The effect of adding the epipodophyllotoxin etoposide (VP-16-213) to a standard chemotherapy regimen for patients with extensive stage small-cell lung cancer was evaluated during a randomized trial. Chemotherapy consisted of vincristine, doxorubicin, and cyclophosphamide (VAC) alone or with etoposide (EVAC). Of 139 patients enrolled, 136 patients were eligible for study and all but five were evaluable for response. The overall objective response was 46% in the VAC group v 70% in the etoposide-treated group (P = .008) with complete response (CR) rates of 12% v 29%, respectively (P = .030). Although the time to the observation of disease progression was significantly longer in the group of patients receiving etoposide (9.6 v 6.5 months, P = .010), overall survival was similar; this was probably due to administration of other agents including etoposide at the time of VAC failure. However, there were noteworthy differences in long-term (greater than or equal to 2 year) survival. Whereas only four (6%) patients treated with VAC lived 2 years, 11 (16%) of the etoposide-treated group did so (P = .100). Two-year failure-free survival was attained in one (2%) of the VAC patients and eight (11%) of the patients treated with etoposide (P = .034). Long-term survivorship, heretofore usually reported in patients with limited stage disease after a variety of treatments, may be possible with this drug combination in the setting of extensive disease.

Adult↗
PubMed1996

Reference ranges of bone mineral density for women in southern England: the impact of local data on the diagnosis of osteoporosis.

The construction of reference ranges that accurately represent the population at large is essential for the correct identification of osteoporosis from bone mineral density (BMD) measurements. In this study, reference data supplied by the manufacturer of the Lunar DPX+ bone densitometer were compared with data obtained locally. Lumbar spine, proximal femur and total body BMD measurements were made in an age-stratified random sample of 702 Southampton women aged 20 to 89 years. Relevant demographic and medical data were recorded for each subject using a questionnaire. Reference curves of BMD (mean +/- SD) were plotted against age for each measurement site and were found to be higher than the manufacturer's reference values at all ages and sites. Exclusion of women with factors known to affect bone mass only served to increase this discrepancy. According to World Health Organisation definitions, osteoporosis may be identified from BMD values alone. Based upon neck of femur BMD values, 100 (14.8%) of the women in this study group were categorized as osteoporotic using local young normal reference data, compared with only 39 (5.8%) using the manufacturer's data. By normalizing for age distribution, these findings were extrapolated to the local population where it was predicted that 26.0% and 10.1% of females over 50 years of age would be classified as osteoporotic using the respective reference ranges. This study clearly illustrates how the numbers of women diagnosed as osteoporotic vary with the use of different reference populations.

Adult↗
PubMed2001

Effect of nutrient intake in lactation on sow performance: determining the threonine requirement of the high-producing lactating sow.

Reproductive performance is steadily increasing within the pork industry; logically, amino acid requirements need to be redefined for sows producing larger litters. The objective of this study was to determine the threonine requirement of the high-producing lactating sow and to determine the effect of lysine on this requirement. A total of 419 PIC C-15 sows were assigned randomly to treatment within parity groups (1, 2, and 3+) and gestation treatment at d 110 of gestation. Lactation diets were formulated to contain 0.80% total lysine (tLYS) with 0.30, 0.35, 0.40, 0.45, 0.50, 0.55, 0.60, or 0.65% total threonine (tTHR) or 1.06% tLYS with 0.40, 0.45, 0.50, 0.55, 0.60, 0.65, or 0.70% tTHR. Litters were standardized to a minimum of 11 piglets within 48 h after farrowing, and sows had free access to feed throughout lactation (lactation length = 20.1 +/- 0.1 d). Sow ADFI exceeded expectation, averaging 6.90, 7.40, and 7.20 kg/d for Parities 1, 2, and 3+, respectively. Daily tLYS intake was 58 g/d (47 g of apparent ileal digestible lysine [dLYS] per day) and 74 g/d (59 g dLYS/d) for the low- and high-lysine group, respectively. Lysine intake did not affect sow or litter performance (P > 0.10). Sows gained an average of 4.8 kg in lactation. Using regression analysis, BW gain was maximized at 0.54% tTHR for all parity groups (quadratic; P < 0.05). Litter weaning weight (67.1, 67.9, and 66.2 kg for Parities 1, 2, and 3+, respectively) and litter weight gain (2.49, 2.53, and 2.44 kg/d for Parities 1, 2, and 3+, respectively) were maximized at 0.53% tTHR using regression analysis, for all parity groups (quadratic; P < 0.05). Based on regression analysis, plasma urea nitrogen on d 10 and 18 was minimized at 0.54% tTHR (P < 0.05). Lysine levels in excess of 58 g of tLYS/d did not benefit sow or litter performance. The requirement for threonine to minimize sow tissue mobilization was 37, 40, and 38 g tTHR/d (28, 30, and 30 g of apparent ileal digestible threonine [dTHR] per day) for Parities 1, 2, and 3+ sows, respectively. The threonine required to maximize litter performance was 36, 39, and 38 g of tTHR/d (28, 30, and 29 g of dTHR/d) for Parities 1, 2, and 3+ sows, respectively. Alternatively, the requirement can be expressed as 14.3 g tTHR (11.8 g dTHR) per kilogram of litter gain.

Animal Nutritional Physiological Phenomena↗