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PubMedDate not supplied

[Analysis of the origins, situation and future perspectives of the health care decentralization process in Spain].

The de-centralisation of health services in any country is a process that involves profound change. This is what has occurred in Spain, where the entities that have received authority for de-centralised services (Autonomous Communities) are regional and have assumed political as well as administrative responsibilities within, what could be defined as, a process of "devolution". Firstly, the reasons behind the Spanish process are analysed. The nature of the process enables it to be confirmed that it has been a result of causes non-related to the health sector, which has had to adapt to the global political change. A second feature is the coinciding of territorial distribution of authority and services with the possibility of further de-centralisation of a functional nature in the managing of health centres and services. The combination of both types of processes has enabled a large number of diversification possibilities for the Spanish Health System. This study refers, in quantitative terms, to the increase or decrease in differences between regions, the de-centralisation process and, therefore analyses certain general qualitative effects. Developing of ways to co-ordinate the health system, to be studied later, has been limited and further developments are necessary in this area. Finally, future prospects of a de-centralised Spanish health system are considered in relation to two principal issues: firstly, the level of difference amongst autonomous health services that is compatible with the ability to maintain health protection for all citizens throughout Spain and, as the case may be, establishing of the limits to guarantee such level; secondly, defining of the relations between autonomous health services in terms of cooperation of competition.

Delivery of Health Care↗
PubMed1998

[A new therapeutic program in advanced ovarian cancer. Good results with decentralized cytostatic therapy].

A trial of decentralised cytostatic (carboplatin + cyclophosphamide) treatment of advanced ovarian cancer under centralised supervision, carried out in the southern health care region, yielded good results. As carboplatin and cyclophosphamide cause myelosuppression which is commonly most manifest two weeks after treatment, increasing dosage intervals and reducing dosages is often necessary. However, compliance with the protocol for increasing dosage intervals and reducing dosages was found to be equally good at Lund and at the various local clinics. Although no significant difference in survival was found between patients treated with carboplatin and cyclophosphamide according to this model and patients treated with cisplatin combined with doxorubicin or epirubicin (P = 0.42), the former protocol is more appropriate for use in the out-patient clinic.

Antineoplastic Agents↗
PubMed1998

[Decentralized high-dose cytostatic treatment with autologous stem cell support].

In the past high-dose chemotherapy with autologous stem cell support in the treatment of certain types of cancer, was centralized to two hospitals in Norway. Almost three years ago it was decided that the treatment should be offered by all five university hospitals. In the northernmost university hospital of Norway, Tromsø, peripheral stem cells were harvested from 29 patients after successful mobilization with chemotherapy and granulocyte colony-stimulating factor (G-CSF). After high-dose chemotherapy, more than 2 x 10(6) CD34-positive stem cells/kg were transplanted in 24 patients and a sign of reconstitution of bone marrow function was achieved with mean time for neutrophils > 0.5x10(9)/l, 9.8 days and for platelets > 20x10(9)/l, 10.8 days. No treatment-related deaths have occurred. Transplantation of selected CD34-positive stem cells has been performed in one patient. Recovery was comparable to the recovery of patients who had undergone transplantation with unselected products. This indicates that even small centres performing as few as ten procedures per year may offer high-dose chemotherapy with autologous stem cell support safely and successfully.

Antigens, CD34↗
PubMed1998

[Decentralized special training in pulmonary medicine. A project using telemedicine].

In arctic Norway, where there is a lack of specialists in pulmonary medicine two postgraduate students, already qualified as specialists in internal medicine at Tromsø Regional Hospital, applied to continue their training at their respective local hospitals. The regional hospital in Tromsø has a long tradition of telemedicine, with network links to local hospitals in the region, and is equipped for interactive consultation and the bilateral transmission of x-rays and video recordings, and digital transmission of x-rays. Accordingly, supported by their supervisor, the two postgraduate students applied to the committee for postgraduate education in pulmonary medicine to have a year's work at their respective local hospitals, supervised via the telemedicine facilities, accepted as equivalent to a six-month module of the normal syllabus. The project was approved and executed as planned. The registrars, who were responsible for pulmonary service at their local hospitals, served four days a month at the regional hospital, and their supervisor visited the local hospitals one day each month. All internal education at the regional hospital was made available by means of a weekly interactive televised link-up, x-rays being displayed on screen as transmitted digitally; bronchoscopies were shown by video, and ad hoc tutorials arranged as needed. Evaluated by the national committee, the project was found satisfactory, and the registrars were duly qualified.

Arctic Regions↗
PubMed1995

Corneal topography of phase III excimer laser photorefractive keratectomy. Optical zone centration analysis. Summit Photorefractive Keratectomy Topography Study Group.

PURPOSE: To determine the amount of optical zone decentration in patients who have undergone excimer laser photorefractive keratectomy (PRK) and assess associations of both decentration and optical zone size with clinical outcomes. METHODS: Optical zone centration in 185 patients after PRK was analyzed using computer-assisted videokeratography. A comparison of decentration among the five study centers was performed. Associations of clinical outcomes with procedure decentration and optical zone size were assessed. RESULTS: Decentration from the pupil center ranged from 0.00 to 1.44 mm (mean, 0.46 mm): 21.8% were decentered 0.25 mm or less, 42.5% > 0.25 mm and < or = 0.50 mm, and 97.1% < or = 1.00 mm. In both eyes, the average decentration from the pupil center was located inferonasally. Decentrations among the five study centers were significantly different. Decentration was associated with attempted refractive correction, change in keratometric cylinder, and patient satisfaction. There was a trend toward worse postoperative uncorrected visual acuity with greater decentration but no association with best-corrected vision, predictability, or refractive astigmatism. No significant relation was found between decentration and glare/halo ranking; however, three of six patients with 1.00 mm or greater of decentration demonstrated a high glare/halo grade. Although optical zone size was not associated with glare or halo, subjective patient satisfaction was greater with a 5.0-mm optical zone than with a 4.5-mm optical zone. CONCLUSIONS: Centration is an important surgeon-controlled variable in excimer laser PRK. Decentration of excimer laser refractive procedures was found to be nonrandom and may be influenced by preoperative pupil management. Moreover, the amount of decentration may influence clinical outcomes. Improved techniques and centering procedures on nonmiotic pupils may improve future results.

Cornea↗
PubMed1997

Effect of local autonomic denervation on in vitro responsiveness of lymphocytes from rat submaxillary lymph nodes.

The local autonomic denervation of rat submaxillary lymph nodes was achieved by a unilateral sympathetic superior cervical ganglionectomy and/or the unilateral section of chorda tympani (that resulted in ipsilateral parasympathetic decentralization of the submandibular territory). This study was performed to determine: (1) whether local sympathetic and/or parasympathetic denervation of rat submaxillary lymph nodes brought about changes in lymph node cellularity, natural killer activity and lipopolysaaccharide (LPS)- and concanavalin A (Con A)-induced cell proliferation in Freund's adjuvant-injected rats; (2) whether the effect of the immunosuppressive drug cyclosporine in rat submaxillary lymph nodes was affected by a single or combined unilateral ganglionectomy plus decentralization. A unilateral ganglionectomy, or the combination of ganglionectomy plus decentralization, performed 7 days earlier, decreased significantly cellularity in ipsilateral submaxillary lymph nodes, while a unilateral decentralization failed to affect it. Natural killer activity increased ipsilaterally after ganglionectomy or decentralization, and decreased after the combined surgical procedure. LPS-induced cell proliferation augmented significantly after ganglionectomy or decentralization, while Con A-induced T lymphocyte proliferation remained unaffected. In the sham-operated side, cyclosporine decreased submaxillary lymph node cell number and natural killer activity, while it increased the proliferative response to LPS. The depressive effect of cyclosporine on lymph node cellularity was no longer observed in ganglionectomized or decentralized lymph nodes, but was found after the combined surgical denervation. Decentralization, or decentralization plus ganglionectomy, blunted the depressive effect of cyclosporine on natural killer activity. The stimulatory effect of cyclosporine on lymphocyte proliferation induced by LPS was reversed both by ganglionectomy or by decentralization and was suppressed by the combined surgical procedure. Neither treatment affected Con A-induced proliferation of T lymphocytes. The results further indicate that an appropriate sympathetic and parasympathetic local environment may be needed for immunomodulation, as well as for cyclosporine activity in lymphoid tissue.

Animals↗
PubMedDate not supplied

Changes in refraction induced by change in intraocular lens position.

BACKGROUND: Intraocular lens (IOL) decentration and tilt may affect postoperative refractive errors through spherical aberration of the IOL. METHODS: Through a use of a ray-tracing program and by minimizing algorithm, we calculated theoretical refractive errors for various degrees of IOL decentration and tilt. We compared our results with those obtained by paraxial vergence calculations. RESULTS: IOL decentration and/or tilt shifted postoperative refractive errors toward myopia and astigmatism of oblique origin. For example, a 3-millimeter decentration of an IOL resulted in induction of approximately -2.00 diopters (D) sphere and +0.70 D cylinder. IOL tilt affected refractive errors to a lesser degree. The change in refractive error caused by a combination of IOL decentration and tilt depended on the relationship between the geometrical axes of decentration and tilt. In the case of the least favorable combination of 12 degrees of tilt and 3 mm of decentration, it can reach -7.00 D sphere and +4.00 D cylinder. CONCLUSIONS: IOL decentration and/or tilt increase myopia and astigmatism. They are negligible for small decentrations, but could be sources of substantial postoperative refractive errors if the decentration or tile is large.

Astigmatism↗
PubMedDate not supplied

Ablation zone centration after photorefractive keratectomy and its effect on visual outcome.

PURPOSE: To determine the relation between ablation zone decentration, measured by corneal topography, and visual and refractive outcome, contrast sensitivity, glare, and subjective reports of halos after photorefractive keratectomy (PRK). SETTING: Eye Foundation, University of Missouri-Kansas City School of Medicine. METHODS: This study comprised 70 eyes of 70 patients enrolled into Phase III of the clinical investigation of the VISX 20/20 excimer laser for the correction by PRK of 1.00 to 6.00 diopters of pre-existing sphere. All patients were treated with 5.0 mm ablation zones. Preoperative and postoperative corneal topography in 67 eyes was done using the EyeSys system. Ablation zone decentration was measured relative to the pupillary center at all postoperative visits as determined from the difference or change map. RESULTS: Mean distance between the ablation zone center and the pupillary center was 0.62 mm +/- 0.34 (SD) (range 0.07 to 1.67 mm). Twenty seven of 66 patients with corneal topography (40.9%) had decentrations less than 0.5 mm; decentrations in 6 eyes (9.1%) were 1.0 mm or more from the pupillary center. No correlation was observed between the magnitude of decentration and 1 year postoperative best spectacle-corrected acuity (r = -.04, P = .76), uncorrected acuity (r = -.03, P = .84), or spherical equivalent (r = -.07, P = .59); preoperative uncorrected acuity (r = .04, P = .73) or spherical equivalent (r = -.02, P = .90); or reduction in spherical equivalent (r = .02, P = .89). The magnitude of decentration was correlated with preoperative spectacle-corrected acuity (r = -.37, P = .002). There was no difference in contrast sensitivity, glare, or halos between the cases with less than 0.5 mm of decentration and those with 0.5 mm or more of decentration. CONCLUSIONS: The degree of ablation zone decentration did not affect postoperative Snellen visual acuity or contrast sensitivity.

Adult↗
PubMed1992

Role for the submandibular gland in modulating pulmonary inflammation following induction of systemic anaphylaxis.

Previous studies have shown that bilateral decentralization of the superior cervical ganglia (SCG; decentralization) attenuates allergen-induced pulmonary inflammatory responses in male rats sensitized to the nematode Nippostrongylus brasiliensis. The present report examines the neuronal and glandular mechanisms mediating the protection against pulmonary inflammation afforded by decentralization. Tissues and organs innervated by the SCG are responsible for this protection since, in a manner similar to decentralization, bilateral removal of the SCG (ganglionectomy) reduced anaphylaxis-induced accumulation of inflammatory cells in bronchoalveolar lavage fluid. Removal of the submandibular gland (sialadenectomy) did not modify the severity of the pulmonary inflammation, but concurrent sialadenectomy and decentralization abolished the protective effect of decentralization. Thus, we postulate that cervical sympathetic nerves tonically inhibit release of anti-inflammatory factors from submandibular glands. No relationship was found between noradrenaline and serotonin content of submandibular glands and the degree of protection against pulmonary inflammation offered by decentralization and ganglionectomy. Both decentralization and ganglionectomy appeared to increase the level of transcripts that encode immunomodulatory growth factors (nerve growth factor and epidermal growth factor) in submandibular glands, but these denervations evidently did not modify the transcripts for TGF beta 2. Systemic inflammatory events are regulated by the central nervous system at a level superior to the SCG probably through modulation of immunoregulatory factors in submandibular glands.

Anaphylaxis↗
PubMed1994

Functional capacity of nicotine-sensitive canine intrinsic cardiac neurons to modify the heart.

The capacity of intrinsic cardiac efferent parasympathetic and sympathetic neurons to modify the heart was investigated in nine anesthetized open-chest dogs with adrenal glands removed from the circulation. The effects elicited by intravenously administered isoproterenol, tyramine, and nicotine on cardiac variables were examined before and after acute decentralization of the heart. Major vessels, as well as other tissues at the base of the heart, were denuded by means of an ultrasonic aspirator that removed neural elements without damaging muscles or blood vessels. The efficacy of the acute decentralization was assured by testing cardiac responses elicited by right and left stellate ganglia and cervical vagosympathetic complex stimulations after surgery. Heart rate, atrial force, and both right and left ventricular intramyocardial systolic pressures were augmented similarly by isoproterenol and tyramine before and after acute decentralization, indicating that the surgery necessary to decentralize the heart did not obtund cardiac myocyte function. Power spectral analysis of heart rate and left ventricular chamber pressure rate of change indicated an almost complete lack of variability of these indexes after, but not before, acute decentralization. Despite these changes, similar cardiac augmentation was elicited by nicotine before and after acute decentralization. Cardiac augmentation was elicited by nicotine in acutely decentralized preparations after atropine administration but not after beta-adrenergic blockade. These data indicate that the canine intrinsic cardiac nervous system contains a significant population of nicotine-sensitive adrenergic neurons that modulate the heart. Furthermore, the intrinsic cardiac nervous system does not appear to be primarily responsible for the heart rate and ventricular pressure variability found in intact hearts.

Animals↗
PubMedDate not supplied

Corneal topographic analysis of photorefractive keratectomy in 175 myopic eyes.

Videokeratography is a useful method for postoperative evaluation of photorefractive keratectomy (PRK). The aim of this study was to evaluate the percentage of decentration, the relationship between decentration relative to the corneal apex, postoperative astigmatism, and the relationship between decentration and best corrected Snellen visual acuity. Using the TMS-1 videokeratoscope we analyzed the corneal topography of 175 myopic eyes treated with PRKs ranging between -1.30 D and -15.90 D, performed using the Summit UV200 193-nanometer excimer laser, before and at least 6 months after the procedure. Concerning centration, 122 eyes (75%) were centered within 0.5 mm and 53 eyes (30.3%) were decentered more than 0.5 mm, with nine eyes (5.1%) being decentered more than 1 mm. There was a correlation between best spectacle corrected visual acuity and the amount of decentration. The higher attempted corrections showed greater amounts of decentration. Postoperative induced astigmatism was greater in the group with the highest decentration (1.81 +/- 2.64 D) than in the one with lower decentration (0.09 +/- 0.50 D). The most severe complication induced by a decentered PRK is an increase of postoperative astigmatism.

Adolescent↗