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PubMed1989

[Hospital financing and information on hospital clients].

The health care system can be characterized, among other facts, by the multiplicity of involved actors (institutions and individuals) acting for final goals in competition, or even in opposition. The principal goal of the economic organization of the health care system consists in applying a regulation to grant the coordination of the great number of decisions taken by decentralized actors in order to introduce them in economic way into a common final goal. The market forces appear unable to realize the necessary regulation in the health care system and centralized planning can lead to lack of effectiveness. For this reason, it's necessary to make use of a decentralized economic regulation; in this view health care financing systems are essential and could positively influence the behaviour of the actors as well as the costs. Information on hospital Casemix represents an important contribution to better transparency of the working of the health care system and to facilitate competition.

Delivery of Health Care↗
PubMed1996

The political development of "Program Realignment": California's 1991 mental health care reform.

This article reviews the legislative process that resulted in the most significant reform of California's public mental health system in nearly 25 years. The reform, termed "Program Realignment," decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states' experiences. These independent variables are an urgent need for action within a limited timeframe, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state's 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California's experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.

Budgets↗
PubMed2005

Preparation of arsenic trioxide albumin microspheres and its release characteristics in vitro.

Arsenic trioxide albumin microspheres (As2O3-BSA-NS) were prepared by using methods of chemical cross-linking. The desirability function (DF), calculated according to the size (<1 microm) distribution, drug loading and drug trapping efficiency, was introduced as a total index for the microspheres formulation. Four factors, inculding W/O ratio, decentralization speed, BSA concentration and stirring stabilization time, were selected and arranged in an orthogonal experimental table. The release characteristic was studied by the drug release experiment in vitro. The four factors affected DF differently. Decentralization speed behaved as the maximum (P<0.01), followed by BSA concentration (P<0.05) and the W/O ratio dose (P<0.05). Stirring stabilization time did not influence DF (P>0.05). The release experiment in vitro showed that As2O3 in As2O3-BSA-NS was released more slower than pure As2O3. It was concluded that regular As2O3-BSA-NS may be prepared by the methods of chemical cross-linking, which was optimized by orthogonal experimental analysis of different factors, and the microspheres can release As2O3 slowly.

Arsenic Trioxide↗
PubMed2000

Workplace and workforce 2000+ -the future of our work environment.

OBJECTIVES: Research in the Human Resource Department at the University of Mannheim is directed towards the exploration of future work structures and design, and their effects on employees and employment relations. METHODS: The main methods applied are trend extrapolation and simulation in combination with delphi research methodology. The trends observed during the last decade suggest that the workplace and workforce in the new millenium will primarily be affected by flexibilization, decentralization, and globalization. RESULTS AND CONCLUSIONS: Flexibilization will lead to a core group with unlimited full employment and an increasing larger group of short-term limited and/or part-time employees who face severe employment risks, ultimately resulting in stress. Flexibilization will also affect the workplace. Information technologies will dissolve social entities. The virtual company suppresses social interaction and will as a consequence create new forms of alienation. Decentralization will increase the responsibility for business processes. Employees will be regarded as business process owners and will be held responsible for their results, a situation which again creates new stress factors. Globalization enhances competition, which in turn will encourage competitive attitudes at the workplace. Internal market mechanisms will take the place of performance appraisals by management. Market evaluation will substitute leadership styles and communication, which stand for the human side of enterprise. The psychosocial problems arising from these developments will produce new challenges for occupational health professionals.

Forecasting↗
PubMed1999

[Point-of-care-testing--the intensive care laboratory].

After successful centralization of laboratory analyses since more than 30 years, advances in biosensors, microprocessors, measurement of undiluted whole blood and miniaturization of laboratory analyzers are leading nowadays more and more to a re-decentralization in the laboratory medicine. Point-of-care-testing (POCT), which is defined as any laboratory test performed outside central or decentralized laboratories, is becoming more and more popular. The theoretical advantages of POCT are faster turn-around-times (TAT), more rapid medical decisions, avoidance of sample identification and sample transport problems and the need of only small specimen volumes. These advantages are frequently mentioned, but are not associated with a clear clinical benefit. The disadvantages of POCT such as incorrect handling and/or maintenance of the analyzers by nontrained clinical staff, inadequate or even absent calibrations and/or quality controls, lack of cost-effectiveness because of an increased number of analyzers and more expensive reagents, insufficient documentation and difficult comparability of the obtained POCT-results with routine laboratory results, are strongly evident. According to the authors' opinion the decision for the establishing of POCT has only to be made in a close co-operation between physicians and laboratorians in order to vouch for necessity and high quality of the analyses. Taking the local situation into consideration (24-h-central laboratory, etc.) the spectrum of parameters measured by means of POCT should be rigorously restricted to the vital functions. Such analytes should be: hemoglobin or hematocrit, activated whole blood clotting time, blood gases, sodium, potassium, ionized calcium, glucose, creatinine, ammonia and lactate.

Clinical Laboratory Techniques↗
PubMed1997

The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990.

Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.

Adult↗
PubMed2004

Land conversion for suburban housing: A study of urbanization around Warsaw and Olsztyn, Poland.

In Poland of the 1990s, urban demand for housing land around city agglomerations increased rapidly. The decreasing profitability of agricultural production also caused farmers to become interested in the sale of agricultural land for nonagricultural purposes, and new land legislation granted them the right to sell their land. Polish counties simultaneously received self-governing status, which allowed them to define the priorities for local development. Counties received additional responsibility for land management and quickly demonstrated strong support for land conversion, which was perceived as a factor of local development. This paper argues that decentralization and the extension of private control over land have led to a loss of rural landscapes in Poland because farmers, county governments, and rural society in general gained from the conversion of agricultural to housing land. Rapid urbanization has significantly reduced the availability of open space around cities and threatened valuable landscapes, for it has occurred in the absence of environmental safeguards. This paper reports findings from research in two counties, located in regions with diverse economic growth rates. Decentralization is particularly problematic if tax regulations and intergovernmental fiscal relations reward local authorities for urbanization but not environmental protection.

Agriculture↗
PubMed1998

Canadian Innovations in Siting Hazardous Waste Management Facilities

/ Siting hazardous waste facilities is an extremely complex and difficult endeavor. Public aversion to the construction of these facilities in or near their community often results in concerted opposition, referred to as the NIMBY syndrome. For the most part, siting processes do not fail because of inadequate environmental or technical considerations, but because of the adversarial decision-making strategies employed by the proponents. Innovative siting processes used in the provinces of Alberta and Manitoba offer tangible evidence of the successful application of an innovative siting approach based on the principles of decentralization of decision-making authority and full and meaningful public involvement. The purpose of this paper is to evaluate four Canadian siting processes from the perspective of public participation and access to decision-making authority. Examples of siting processes related to hazardous waste management facilities are provided from the provinces of Alberta, Manitoba, British Columbia, and Ontario. Siting has evolved from approaches dominated by top-down decision making to increasing decentralized and pluralistic approaches. Focusing on social and political concerns of potentially affected communities and on the process of decision making itself are fundamental to achieving siting success. In Alberta initially, and later in Manitoba, this new "open approach" to siting has resulted in the construction of the first two comprehensive hazardous waste treatment facilities in Canada.KEY WORDS: Hazardous waste facilities; Siting methodologies; Public participation

Journal Article↗
PubMed2002

[Complications with foldable intraocular lenses with subsequent explantation in 1998 and 1999. Results of a questionnaire evaluation].

PURPOSE: A questionnaire was sent to all members of the German Society of Ophthalmic Surgeons to evaluate complications of foldable intraocular lenses (IOLs) that required explanation. METHODS: Information on preoperative visual acuity, foldable IOL design and material as well as the reason for IOL explantation was obtained and analysed. We received 167 completed questionnaires for 1998 and 1999. RESULTS: In 1998 and 1999 the most common reasons for IOL explantation were as follows: incorrect lens power for 56% of the 3-piece hydrophobic acrylic IOLs, 16% because of glare or other photic phenomena, 40% of the 1-piece hydrophilic acrylic IOLs were explanted because of incorrect lens power and 30% for IOL damage. For the 3-piece monofocal silicone IOLs, 41% were explanted because of incorrect IOL power and 32% because of IOL decentration. For the 1-piece Hydrogel IOL, 76% were explanted because of opacification of the optic and 14% because of incorrect lens power. Most multifocal IOLs were explanted because of photic phenomena. CONCLUSION: In addition to the most common complications such as decentration and incorrect IOL power observed in rigid IOLs, new complications associated with foldable IOLs occurred such as optic opacification, glare and photic phenomena. Some complications seemed to appear in particular IOL types (opacification: SC-60BOUV, MDR), while others were observed in all types of foldable lenses. Accurate calculation of the IOL power and further improvement of the IOL material and design seem to be necessary to minimise the rate of explantations.

Device Removal↗
PubMed2003

[Complications of foldable intraocular lenses requiring explantation. Results of the 2000 and 2001 survey in Germany].

PURPOSE: A survey was sent to all members of the German Society of Ophthalmic Surgeons to evaluate complications that required explantation of foldable intraocular lenses (IOLs). METHODS: Data on preoperative visual acuity, foldable IOL design and material, and the reason for explantation were obtained and analysed. We received 185 surveys for 2000 and 2001. RESULTS: In 2000 and 2001, the most common reasons for IOL explantation were: incorrect lens power (31%) and dislocation (19%) in three-piece acrylic IOLs, incorrect power (31%) and decentration (17%) in monofocal silicone IOLs, and opacification (46%) in hydrophilic IOLs. The most common reasons for the exchange of monofocal IOLs were lens opacification in 2000 and incorrect IOL power in 2001. CONCLUSION: Besides the most frequent complications of decentration and incorrect power observed in rigid IOLs,new complications associated with foldable IOLs occurred (e.g., optic opacification and calcification). Accurate calculation of IOL power and further improvements in material and design are still necessary to minimize the rate of explantations.

Acrylates↗
PubMed2007

[Ablation on the undersurface of a LASIK flap. Instrument and method for continuous eye tracking].

BACKGROUND: The risk of iatrogenic keratectasia after laser in situ keratomileusis (LASIK) increases with thinner posterior stromal beds. Ablations on the undersurface of a LASIK flap could only be performed without the guidance of an eye tracker, which may lead to decentration. A new method for laser ablation with flying spot lasers on the undersurface of a LASIK flap was developed that enables the use of an active eye tracker by utilizing a novel instrument. The first clinical results are reported. PATIENTS AND METHODS: Patients wishing an enhancement procedure were eligible for a modified repeat LASIK procedure if the flaps cut in the initial procedure were thick enough to perform the intended additional ablation on the undersurface leaving at least 90 microm of flap thickness behind. (1) The horizontal axis and the center of the entrance pupil were marked on the epithelial side of the flap using gentian violet dye. (2) The flap was reflected on a newly designed flap holder which had a donut-shaped black marking. (3) The eye tracker was centered on the mark visible in transparency on the flap. (4) Ablation with a flying spot Bausch & Lomb Technolas 217z laser was performed on the undersurface of the flap with a superior hinge taking into account that in astigmatic ablations the cylinder axis had to be mirrored according to the formula: axis on the undersurface=180 degrees -axis on the stromal bed. (5) The flap was repositioned. RESULTS: Detection of the marking on the modified flap holder and continuous tracking instead of the real pupil was possible in all of the 12 eyes treated with this technique. It may be necessary to cover the real pupil during ablation in order not to confuse the eye tracker. Ablation could be performed without decentration or loss of best spectacle-corrected visual acuity. Refractive results in minor corrections were good without nomogram adjustment. CONCLUSIONS: Using this novel flap holder with a marking that is tracked instead of the real pupil, centered ablations with a flying spot laser on the undersurface of a LASIK flap are feasible. Thus, the additional risk of iatrogenic keratectasia associated with stromal enhancement ablations is avoided.

Adolescent↗
PubMed1999

Has deinstitutionalization gone too far?

Modern social psychiatry is aiming at integration of the mentally disordered in the community instead of institutionalization--with or without institutions. No doubt, the majority of mentally disordered patients have benefitted greatly from deinstitutionalized psychiatry. Unfortunately, in the implementation of deinstitutionalized psychiatry, there has widely been a gap between the closure of the mental hospitals and the building up of the decentralized services. Instead of organizing decentralized services and then gradually reducing the capacity of hospital treatment, things happened in many places the other way around. With data from the nationwide Danish Psychiatric Case Register, the author documents a series of negative indicators that have appeared parallel with the deinstitutionalization process. * 100% increase in standard mortality rate of suicides for non-organic psychotic patients * an exponential increase of 6.7% annually in number of criminal mentally disordered * increase in coercive activities in the wards several hundred per cent for some of the measures * increase in bed occupancy rate from approximately 80% to 100% * Acute admission rates between 85% and 90% * No signs of reduction in 1 year readmission rate of first time diagnosed schizophrenics from the very stable 45%-50% which has been seen for almost 20 years. Beyond any doubt, social psychiatric rehabilitation is needed. An increase in the capacity in the psychiatric services and fitting of the treatment models to the patients' needs so that the negative aspects we have seen can be properly handled must be on top of the agenda in the next few years.

Acute Disease↗
PubMed1996

Increased expression of nitric oxide synthase in a subpopulation of rat sympathetic neurons after axotomy - correlation with vasoactive intestinal peptide.

Nitric oxide synthase (NOS) expression is increased in peripheral sensory and central motor neurons after axotomy. By applying double-labelling immunofluorescence and non-radioactive in situ hybridization, we have investigated the regulation of NOS in axotomized sympathetic rat superior cervical ganglia. Furthermore, co-localization of NOS with vasoactive intestinal peptide, which is also induced by axotomy, has been examined. Very few (<0.1%) NOS-expressing neurons are observed in control ganglia. Some large cell bodies located at the exit of the internal carotid nerve are additionally immunoreactive for vasoactive intestinal peptide. One week following postganglionic axotomy, the number of NOS-immunoreactive and NOS mRNA-expressing neurons increases but does not exceed 2% of the whole neuronal population. About 20% of these neurons are also immunoreactive for vasoactive intestinal peptide. Preganglionic nerve fibre meshworks that are immunoreactive for NOS in untreated ganglia disappear after ganglionic decentralization, whereas some presumably postganglionic fibres remain visible after combined axotomy and decentralization. The findings are indicative of an increased synthesis of NOS in a small subset of postganglionic neurons of the rat superior cervical ganglion, possibly because of the loss of target-derived factors that inhibit nitric oxide synthesis under normal conditions.

Adrenergic Fibers↗
PubMedDate not supplied

Relationship between corneal aberrations and contrast sensitivity after hyperopic laser in situ keratomileusis.

PURPOSE: To evaluate the relationship between corneal aberrations and contrast sensitivity (CS) after hyperopic laser in situ keratomileusis (H-LASIK). METHODS: In 13 patients (13 eyes) who underwent H-LASIK, we measured CS and corneal topography preoperatively and at 1 year postoperatively. Photopic and scotopic CS values were measured at 3, 6, and 12 cycles/degree (cpd) using an MCT-8000 contrast tester. Corneal aberrations were determined from the data on corneal topography using CTView. The corneal high-order aberrations were defined as the sum of the third- and fourth-order aberrations in the 4-mm zone and the sum of the third- to sixth-order aberrations in the 6-mm-zone. RESULTS: Under scotopic conditions at 12 cpd, the changes in CS significantly correlated with changes in the corneal aberrations. Scotopic CS was significantly deteriorated by glare, but photopic CS was not significantly changed. H-LASIK induced a significant increase in corneal aberrations that positively correlated with the amount of correction, regardless of the improvement in logMAR corrected visual acuity. LogMAR corrected visual acuity did not significantly correlate with corneal aberrations. Furthermore, decentration significantly correlated with the changes in the 6-mm zone corneal aberrations. CONCLUSIONS: In eyes after H-LASIK, the changes in scotopic CS significantly correlated with those in the corneal aberrations, which might have resulted from decentration or ablation profiles in H-LASIK and a relatively small optical zone. Further studies will be needed to validate this relationship.

Adult↗
PubMed1980

Adrenal influence on tyrosine hydroxylase activity in superior cervical ganglion.

The involvement of adrenal hormones as regulatory factors in maintaining physiological levels of tyrosine hydroxylase (TH) was examined in mouse superior cervical ganglion. Following bilateral adrenalectomy, TH activity in the ganglion fell at a slow but steady rate, reaching 60-65% of the control levels after 2 weeks. Decentralization is known also to reduce TH activity in the ganglion. The effects of adrenalectomy and decentralization were therefore compared, and they were found to be additive, indicating different mechanisms in the two cases. The reduction of TH activity following adrenalectomy was not prevented by replacement with corticosterone (0.5 mg/kg, daily). However, replacement with epinephrine (4 mg/kg, daily) completely prevented the fall of TH activity in adrenalectomized animals. Isoproterenol, a beta-adrenergic receptor agonist, was as effective as epinephrine in preventing the reduction of TH activity following adrenalectomy. Furthermore, in intact animals, chronic administration of SKF 64139, an inhibitor of adrenal PNMT which depletes circulating epinephrine levels, also reduced ganglionic TH activity to the same level as that after adrenalectomy. These results indicate that epinephrine, but not corticosterone, is the adrenal factor required for physiological maintenance of normal levels of TH in the superior cervical ganglion.

Adrenal Glands↗
PubMed1981

Effect of nerve activity on transport of nerve growth factor and dopamine beta-hydroxylase antibodies in sympathetic neurones.

The effect of nerve activity on the uptake and retrograde transport of nerve growth factor (NGF) and dopamine beta-hydroxylase (DBH) antibodies was studied by injecting 125I-labelled NGF and anti-DBH into the anterior eye chamber of guinea-pigs. Decentralization of the ipsilateral superior cervical ganglion (SCG) had no significant effect on the retrograde transport of either NGF or anti-DBH. Phenoxybenzamine produced a 50% increase in anti-DBH but not NGF accumulation and this effect was prevented by prior decentralization. This demonstrates that NGF is taken up independently of the retrieval of synaptic vesicle components.

Adrenergic Fibers↗
PubMed1985

Trans-synaptic increase in RNA coding for tyrosine hydroxylase in a rat sympathetic ganglion.

To begin examining molecular mechanisms underlying trans-synaptic regulation, tyrosine hydroxylase (TH) and its messenger RNA (mRNA) were examined in the superior cervical sympathetic ganglion (SCG) of adult rats. Basal levels of TH mRNA were detectable in control ganglia by RNA dot hybridization, using the 32P nick translated PstI-KpnI restriction fragment of pTH.4 as a probe. Reserpine induced a 3-fold rise in TH activity per microgram protein, and a simultaneous 3-fold increase in ganglion TH mRNA. As expected, ganglion decentralization (denervation) prevented the trans-synaptic induction of TH. In addition, decentralization prevented the increase in TH mRNA, suggesting that the increase in message was dependent on trans-synaptic stimulation. Northern blot analysis indicated that the cDNA (complementary DNA) probe hybridized to a single band of approximately 1900 nucleotides, which was the same size in all ganglia. Our observations indicate that induction of TH is associated with a trans-synaptic increase in mRNA coding for the enzyme. Consequently, trans-synaptic increases in impulse activity may induce TH by increasing neuronal levels of TH mRNA in the SCG.

Animals↗
PubMed1987

Two discrete enkephalinergic neuron systems in the superior cervical ganglion of the guinea pig: an immunoelectron microscopic study.

Leucine-enkephalin (L-ENK)-like immunoreactive (L-ENKI) structures in the superior cervical ganglion (SCG) were first examined by using immunoelectron microscopy. L-ENKI neurons formed cell clusters and were small. They were filled with large granular or agranular vesicles and small electron lucent vesicles, and had nuclei that lacked a nucleolus. Since these morphological characteristics are identical to those of the small intensely fluorescent (SIF) cells, L-ENKI cells seemed to be a kind of SIF cell. Two types of L-ENKI fibers were identified, a large type filled with large granular or agranular vesicles and a small type filled with small electron lucent vesicles. The large fibers were located near the L-ENKI perikarya and often could be traced directly to the soma. These fibers remained intact after decentralization of the SCG. These findings indicate that the large L-ENKI fibers are processes of L-ENKI SIF cells. The fibers showed a close apposition to the blood vessels and rarely formed synaptic contact with dendrites of the principal cells. On the other hand, the small L-ENKI fibers were found to originate outside the SCG, because they disappeared after decentralization of the SCG. These L-ENKI fibers frequently formed synaptic contact with the dendrites of the principal cells. Thus, the present study demonstrated the presence of two discrete L-ENKI neuron systems in the SCG of the guinea pig, one an intrinsic SIF system and the other an extrinsic L-ENKI system.

Animals↗