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PubMed1995

Effects of acutely raising intracranial pressure on cardiac sympathetic efferent neuron function.

OBJECTIVE: To determine whether acutely raising intracranial pressure modifies the function of cardiac efferent autonomic neurons. METHODS: The effects of suddenly raising intracranial pressure above systemic vascular pressure on heart rate, left atrial and left ventricular chamber pressures, as well as right and left ventricular intramyocardial pressures, were studied following removal of the adrenal glands from the circulation. Cardiac effects induced by systemic administration of nicotine, tyramine or isoproterenol were investigated before and after raising intracranial pressure: (1) in 9 dogs with neurally intact hearts in which cardiac release of catecholamines and intrinsic cardiac neuronal activity were studied; (2) in another 8 dogs in which intrathoracic autonomic neurons were disconnected from central neurons; (3) in another 8 dogs after decentralizing intrathoracic sympathetic but not parasympathetic neurons; (4) in 2 animals after decentralizing intrathoracic parasympathetic, not sympathetic neurons. RESULTS: Increasing intracranial pressure in neurally intact preparations induced ventricular augmentation followed by depression such that after 12 min of cerebral ischemia left ventricular systolic pressure was 62 +/- 5 mmHg. Isoproterenol and tyramine augmented right ventricular inotropism similarly before and after raising intracranial pressure, their effects on left ventricular systolic pressures being reduced secondary to the systemic vascular hypotension. Although nicotine excited intrinsic cardiac neurons similarly before and after raising intracranial pressure, it failed to enhance cardiac liberation of noradrenaline after compared to before raising intracranial pressure. Nicotine-induced ventricular augmentation was obtunded after brain death despite the fact that ventricular myocytes underwent no detectable histological changes. In contrast, nicotine induced similar cardiac augmentation before and after raising intracranial pressure when intrathoracic autonomic neurons or when intrathoracic sympathetic, not parasympathetic neurons, were decentralized. CONCLUSION: Cardiac sympathetic efferent neuronal function is obtained by acutely raising intracranial pressure.

Adrenalectomy↗

PubMed1998

In vitro evaluation of the efficacy of the capsular tension ring for managing zonular dialysis in cataract surgery.

BACKGROUND AND OBJECTIVE: In vitro evaluation of the capsular tension ring for managing zonular dialysis in cataract surgery. MATERIALS AND METHODS: Pig and cadaver eye models were used in this study. Lens material was removed with phacoemulsification, then the zonules were cut in one quadrant of the meridian to induce capsular bag decentration. Posterior chamber intraocular lenses (PC IOLs) were implanted into the bag with or without the tension rings. The IOL and the tension ring positions were viewed using the Miyaki technique. PC IOLs were also implanted into isolated capsular bags with or without tension rings, and bag configuration was examined. RESULTS: The IOL decentration was observed when the IOLs were implanted into the eyes without zonular support in one quadrant of the meridian. No IOL decentration was observed when the tension ring and the IOL were implanted together. When only the IOLs were inserted into the isolated bags they became oval, whereas the circular bags were preserved when both the IOL and the tension ring were placed in-the-bag. CONCLUSION: The authors' in vitro model demonstrated that the capsular tension ring maintained the circular contour of the capsular bag and IOL centration in the eyes with broken zonules. The results suggest that capsular tension rings may provide an alternative means to manage zonular dialysis during phacoemulsification and PC IOL implantation.

Animals↗

PubMed1998

Specific targeting of ganglion cell sprouts provides an additional mechanism for restoring peripheral motor circuits in pelvic ganglia after spinal nerve damage.

The pelvic ganglia contain both sympathetic and parasympathetic neurons and provide an interesting model in which to study the effects of a distributed spinal nerve lesion. Previous animal studies have suggested that after either lumbar or sacral nerve injury, some functional connections are restored between preganglionic and postganglionic neurons. It has been proposed that this is because of intact preganglionic axons sprouting collaterals to supply denervated ganglion cells. However, this has never been demonstrated, and our study has investigated whether the ganglion cells themselves contribute to axogenesis and restoration of peripheral circuitry. We have monitored the growth of axons from pelvic ganglion cells after lumbar or sacral nerve injury (partial decentralization), or a combination of the two (total decentralization). These new processes were distinguished from intact preganglionic terminals by their immunoreactivity for substances present only in pelvic ganglion neurons (vasoactive intestinal peptide, neuropeptide Y, and tyrosine hydroxylase). The proportion of pelvic neurons surrounded by these immunostained fibers was then assessed. Complete removal of preganglionic terminals provides the biggest stimulus for growth of new axon processes (sprouts), which grow profusely within just a few days. These arise from each of the main chemical classes of pelvic neurons but grow at different rates and have different distributions. Importantly, some chemical classes of sprouts preferentially supply neurons of dissimilar histochemistry, suggesting the presence of very specific targeting mechanisms rather than random growth. These sprouts are transient, however, those formed after partial decentralization appear to be maintained. Moreover, after lesion of either lumbar or sacral spinal nerves, many sprouts arise from neurons with intact spinal connections and innervate neurons that have lost their preganglionic inputs. This provides a very different alternative mechanism to reestablish communication between preganglionic and postganglionic neurons. In conclusion, we have demonstrated a rapid and selective axogenesis within the pelvic ganglion after spinal nerve injury. This may allow the development of novel strategies by which autonomic nerve pathways can be experimentally manipulated, to facilitate more rapid return of appropriate peripheral reflex control.

Animals↗

PubMed1989

Growth determinants in the core-periphery of Korea.

"This article describes the emergent spatial dispersion pattern of the urban system of the Republic of Korea, where the government has instituted a strong decentralization policy. Intraregional decentralization is underway within the core area, while intraregional polarization towards larger regional centers is evident in periphery areas. Through the use of step-wise regression analysis, determinants of the differential growth rates of urban centers in the core and periphery are identified. The different spatial development processes operating in the core and periphery have implications for growth pole theory and regional development planning."

Asia↗

PubMed1995

Pancreatic surgery. A paradigm for progress in the age of the bottom line.

The past few decades have seen great change in the capabilities of medical care. The next decade will emphasize great change in its delivery, driven mainly by the necessity of containing costs presently running at more than 13% of the gross national product. The current perception is that two of the principal causes of the excessive cost of medical care in the United States are the price of new technology and the fact that much of the care rendered is by specialists. In fact, most surgical care can be rendered by general surgeons, and the coming changes will revitalize the demand for and self-esteem of general surgeons. Managed care will recognize this by using general surgeons and keeping patients "down on the farm," a line drawn from the World War I era song entitled "How can you keep them down on the farm after they've seen Paree?" But some things are still unique to the medical equivalent of Paris, perhaps including more complex forms of treatment, the acquisition of knowledge, and teaching. The questions are: what should we decentralize and how do we discriminate what should remain decentralized in the community for economy, and what might be concentrated to good advantage in the centers? I would like to offer the pancreas as a paradigm in thinking about these issues.

Academic Medical Centers↗

PubMed1996

Couple-based prenatal screening for cystic fibrosis in primary care settings.

This study examines a couple-based screening protocol for cystic fibrosis (CF) during pregnancy. The screening test is positive only when both partners carry an identifiable mutation. The risk for the fetus to be homozygous is 1 in 4, and definitive prenatal diagnostic testing can be offered. Between six and seven of every ten CF cases can be identified by testing for seven CF mutations. Couple screening for CF has not been evaluated in a decentralized health-care system. Office guides, informational materials, and consent forms were provided to 69 physicians in Maine. Women sent buccal samples to the study centre and brought sampling materials to their partners. Samples from both individuals were required. When a mutation was identified in the woman's sample, the partner's sample was tested. Screening results were reported to the physician. Standardized follow-up surveys were carried out in selected women, key office staff, and physicians. 1770 women and 1682 partners submitted samples. Testing was successfully completed for 1645 couples. Screening results were positive in one couple; the fetus was homozygous for CF. Physicians, office staff, and nearly all women were satisfied with the screening process. Couple screening for CF is feasible and acceptable in decentralized primary care settings.

Adult↗

PubMedDate not supplied

Hospital autonomy: the experience of Kenyatta National Hospital.

An increasing number of countries are exploring the introduction or expansion of autonomous hospitals as one of the numerous health reforms they are introducing to their health system. Hospital autonomy is one of the forms of decentralization that is focused on a specific institution rather than on a political unit. It has gained much interest because it is an attempt to amalgamate the best elements of the public and private sectors in how a hospital is governed, managed and financed. This paper reviews the key elements of the concept of hospital autonomy, the reasons for its expanded use in many countries and a specific example of making a major teaching hospital autonomous in Kenya. A review of the successful experience of Kenyatta National Hospital and its process of introducing autonomy, with regard to governance, operations and management, and finances, lead to several conclusions on replicability. The legal framework is a critical element for successfully structuring the autonomous hospital. Additionally, success is highly dependent on the extent to which there is adequate funding during the process of attaining autonomy due to the length of the transition period needed. Autonomy must be granted within the context of the national health system and national health objectives and be consistent with those aims and their underlying societal values. Finally, as with decentralization, success is dependent upon the preparation done with the systems and management necessary for the proper governance and operation of autonomous hospitals.

Decision Making, Organizational↗

PubMedDate not supplied

District health systems in a neoliberal world: a review of five key policy areas.

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.

Community Health Planning↗

PubMedDate not supplied

Inequalities in self-reported health within Spanish Regional Health Services: devolution re-examined?

There is evidence of small inter-regional inequalities in both health and health expenditure both before and after the decentralization of the Spanish National Health Service (Spanish NHS). However, it still has not been established whether devolution has exerted any influence on the development of intra-regional inequalities in health. This study examines the existence of socioeconomic health inequalities within the different Spanish healthcare services, using concentration indices. Data were taken from the most recent Encuesta Nacional de Salud (Spanish National Health Survey, 1997) and self-perceived health was used to measure health. It is argued that while inter-regional inequalities in health may have been unaffected by decentralization, intra-regional inequalities may be the undesired consequences of an efficiency-based NHS. The results suggest that devolution may have helped pro-equity policies but only in areas where the private sector is small.

Aged↗

PubMed1994

Taxol-treated fibroblasts acquire an epithelioid shape and a circular pattern of actin bundles.

The effects of two microtubule-specific drugs, taxol and colcemid, upon the cell shape and cytoskeleton of several types of cultured fibroblastic cells were compared. While colcemid depolymerized completely the whole microtubular system, taxol induced decentralization of this system, leading to formation of numerous free microtubules filling the central cytoplasm. Morphometric determinations of two cell shape parameters, dispersion and elongation (G. Dunn and A. Brown, J. Cell Sci. (1986) 83, 313-340), have shown that, in all the tested cultures, taxol induced significantly larger decreases of average dispersion than colcemid; in addition, most taxol-treated cells, but not colcemid-treated ones, developed circumferential bundles of actin microfilaments instead of straight bundles. These results show that decentralization of the microtubular system, in contrast to its complete depolymerization, leads to the transformation of a polarized "fibroblast-like" cell morphology to an "epithelioid" morphology characterized by the smooth discoid cell shape and a circular actin pattern. Possible mechanisms of this transformation are briefly discussed.

3T3 Cells↗

PubMed2001

Sustainable wastewater management for small communities in the Middle East and North Africa.

Accelerated expansion of wastewater services to small communities in the Middle East and North Africa (MENA) is essential in order to address serious concerns over water scarcity and pollution in addition to meeting the demand for convenience and protecting public health. Centralized and conventional wastewater systems are currently the preferred choice of planners and decision-makers in MENA. Water and funding are not available to provide these centralized conventional services to small communities. This paper presents an integrated approach to sustainable wastewater management for small communities in MENA under the severe water resources crisis. The approach calls for a paradigm shift from centralized conventional wastewater systems to decentralized wastewater systems. Management of wastewater in MENA should start at home. Wastewater generation should be reduced through a combination of domestic water conservation measures. On-site systems must be improved and monitored to control pollution and to recover water for non-potable water uses. Should the circumstances not allow the use of on-site systems, wastewater should be transported and managed through a community system applying the principles of decentralized wastewater management and using the settled sewers for wastewater transportation where appropriate. This approach will facilitate the accelerated and sustainable extension of environmentally responsible wastewater services to MENA's small communities. It offers great potential for cost reduction, accommodates the necessary domestic water conservation efforts, reduces freshwater inputs in wastewater transportation thus eliminating unnecessary demand on freshwater, reduces associated environmental risks and increases wastewater reuse opportunities.

Africa, Northern↗

PubMed1987

Neurofilament-like and glial fibrillary acidic protein-like immunoreactivities in rat and guinea-pig sympathetic ganglia in situ and after perturbation.

The presence of neurofilament (NF)-like and glial fibrillary acidic protein (GFAP)-like immunoreactivities was studied in sympathetic ganglia of adult rats and guinea pigs during normal conditions and after perturbation. In the superior cervical ganglion (SCG) of normal rats, many ganglion cells and nerve fibers show NF immunoreactivity. Some of these nerve fibers disappear after preganglionic decentralization of SCG; this indicates the presence of a mixture of pre- and postganglionic NF-positive nerves in the ganglion. Cuts in both pre- and postganglionic nerves result in a marked increase in GFAP immunoreactivity in SCG, whereas NF immunoreactivity increases in nerve cell bodies after preganglionic cuts. Only a few ganglion cells show NF immunoreactivity in the normal SCG of guinea pig. All intraganglionic NF-positive nerves are of preganglionic origin; decentralization abolishes NF immunoreactivity in these nerve fibers. The inferior mesenteric ganglion, the hypogastric nerves and colonic nerves in guinea pigs contain large numbers of strongly NF-immunoreactive nerve fibers. When the SCG of adult rat is grafted to the anterior eye chamber of adult rat recipients, both ganglionic cell bodies and nerve fibers, forming on the host iris from the grafted ganglion, are NF-positive. As only the perikarya of these neurons normally exhibit NF immunoreactivity, and the terminal iris arborizations are NF-negative, it appears that the grafting procedure causes NF immunoreactivity to become more widespread in growing SCG neurons.

Animals↗

PubMedDate not supplied

Swedish health care delivery system and its effects on surgical education.

Sweden, with a small, decentralized population, has a similarly decentralized network of hospitals that comprise the national health care system, which is nonetheless highly regulated by the national government. Medical education and graduate training in surgery are likewise regulated. Reforms implemented in 1992 made a 21-month general rotating internship mandatory for all medical graduates, after which they enter specialty training. The training, which lasts a minimum of 5 years, is done under the tutelage of a Board-certified practitioner in the field. During the trainee and program contract for the amount of time spent in clinical and didactic experiences, the trainee is personally responsible for ensuring that much of his or her individual program is accomplished. Rising health care costs have spurred increased rationalization of resources and are expected to constrict training opportunities for future surgeons.

Delivery of Health Care↗

PubMed1982

Degeneration activity of the pineal gland after sympathetic denervation.

After removal of the superior cervical ganglia the pineal gland of the rat showed a period of transient increase in activity of serotonin-N-acetyltransferase. This degeneration activity was preceded by a decline of the levels of endogenous noradrenaline and an impairment of the 3H-metaraminol uptake. Twenty-seven hours after sympathetic denervation the levels of the endogenous neurotransmitter were almost completely depleted, while either 24 h or 21 days after denervation total uptake of the tritiated amine decreased to only about 50% of the control values. Previous chronic sympathetic decentralization elicited in the pineal gland post-junctional supersensitivity, as judged by the enhanced degeneration activity observed in decentralized glands after sympathetic denervation. The present findings confirm that, in endocrine glands and similarly to other autonomically innervated organs, acute denervation induces degeneration activity.

Animals↗

PubMed1976

Mechanisms of tyrosine hydroxylase and dopamine beta-hydroxylase induction in organ cultures of rat sympathetic ganglia by potassium depolarization and cholinomimetics.

It was the aim of the present study to elucidate the mechanisms involved in specific tyrosine hydroxylase (TH) and dopamine beta-hydroxylase (DBH) induction by potassium depolarization and cholinomimetics in rat superior cervical ganglia kept in organ culture. The effect of high (54 mM) potassium concentration on intact ganglia seems to result in a dual action: a) a specific induction of TH and DBH via release of acetylcholine from preganglionic cholinergic nerve terminals. b) a non-specific effect on terminal adrenergic neurons resulting in a general increase of protein synthesis as indicated by the increase in DOPA decarboxylase (DDC) and monoamine oxidase (MAO) activities. In decentralized superior cervical ganglia potassium depolarization failed to produce the specific TH and DBH induction although a small increase in DDC activity persisted. Carbamylcholine, acetylcholine and nicotine at concentrations of 10(-4) M elicited a selective induction of TH and DBH both in intact and decentralized ganglia via nicotinic receptor stimulation. Bethanechol, predominantly stimulating muscarinic receptors had no significant effect on TH activity. A 4 h pulse of 10(-4) M carbamylcholine produced optimal induction of DBH and TH 24 h and 48 h later respectively. Longer exposure to carbamylcholine resulted in a significantly smaller rise in TH activity.

Acetylcholine↗

PubMed1975

Dopamine-induced neurogenic vasodilatation in isolated perfused muscle preparation of the dog.

Dopamine, injected into the lumbar aorta of the dog in doses which produce a reversible inhibition of synaptic transmission in the lumbar paravertebral ganglia (0.5-64x10-8 moles), produces a neurogenic vasodilatation in the isolated perfused hindleg or gracilis muscle. This was abolished by acute preganglionic decentralization and by administration into the perfused preparation of alpha-adrenoceptor blocking agents, but not of atropine or diphenhydramine. After decentralization, preganglionic electrical stimulation restored the dopamine-induced indirect vasodilatation. The neurogenic vasodilatation was also seen with intra-aortic injections of epinine (2-32x10-8 moles) and apomorphine (1.2-19.2x10-8 moles) and was preferentially blocked by haloperidol (0.26x10-6 moles). (-)-Noradrenaline, injected into the lumbar aorta in baroreceptor-denervated dogs, was found to be equipotent with dopamine in eliciting the neurogenic vasodilatation; this (-)-noradrenaline-induced effect was preferentially blocked by phentolamine (8x10-6 moles). The possibility that the neurogenic vasodilatation, which occurs upon intra-aortic injection of dopamine in the dog, is due to its gnaglionic-inhibitory effect is discussed.

Acetylcholine↗

PubMed1983

Medical computing in the 1980s. Operating system and programming language issues.

Operating systems and programming languages differ widely in their suitability for particular applications. The diversity of medical computing needs demands a diversity of solutions. Compounding this diversity if the decentralization caused by evolution of local computing systems for local needs. Relevant current trends in computing include increased emphasis on decentralization, growing capabilities for interconnection of diverse systems, and development of common data base and file server capabilities. In addition, standardization and hardware in dependence of operating systems, as well as programming languages and development of programmerless systems, continue to widen application opportunities.

Computers↗

PubMed1993

Decentered ablation zones resulting from photorefractive keratectomy with an erodible mask.

Four patients underwent photorefractive keratectomy for compound myopic astigmatism using the erodible mask. All achieved improvements in unaided visual acuities despite manifesting varying levels of decentration of the ablated zones. However, one patient had significant monocular diplopia because of the severity of the decentration. The problems with the present system include the use of a NON coaxial microscope; difficulty with obtaining and maintaining proper alignment of the excimer laser beam to the erodible mask and the central corneal zone; the inability to interrupt and restart the procedure due to the ablation of the reference marks on the mask; and patient discomfort. We suggest installation of the PMMA mask at the laser aperture in order to alleviate the above difficulties. In the meantime, use of a coaxial microscope, a limbal suction device for fixation, permanent reference marks on the mask and peribulbar anaesthesia may be helpful.

Adult↗