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PubMed2004

Crystal structure of a novel antifungal protein distinct with five disulfide bridges from Eucommia ulmoides Oliver at an atomic resolution.

EAFP2 is a novel antifungal protein isolated from the bark of the tree Eucommia ulmoides Oliver. It consists of 41 residues and is characterized with a five-disulfide motif and the inhibitory effects on the growth of both cell wall chitin-containing and chitin-free fungi. The crystal structure of EAFP2 at an atomic resolution of 0.84 A has been determined by using Shake-and-Bake direct methods with the program SnB. The phases obtained were of sufficient quality to permit the initial model built automatically and the structural refinement carried out using anisotropic displacement parameters resulted in a final crystallographic R factor of 6.8%. In the resulting structural model, all non-hydrogen protein atoms including an unusual pyroglutamyl acid residue at the N-terminal can fit to the articulated electron densities with one centre and more than 65% of the hydrogen atoms in the protein can be observed as individual peaks in the difference map. The general fold of EAFP2 is composed of a 3(10) helix (Cys3-Arg6), an alpha-helix (Ala27-Cys31) and a three-stranded antiparallel beta-sheet (Cys16-Ser18, Cys23-Ser25, and Cys35-Cys37) and cross-linked by five disulfide bridges. The tertiary structure of EAFP2 can be divided into two structural sectors, A and B. Sector A composed of residues 11-30 adopts a conformation similar to the chitin-binding domain in the hevein-like proteins and features a hydrophobic surface embraced a chitin-binding site (Tyr20, 22, 29, and Ser18). The distinct disulfide bridge Cys7-Cys37 connects the N-terminal ten residues with the C-terminal segment 35-41 to form the sector B, which features a cationic surface distributing all four positively charged residues, Arg6, 9, 36, and 40. Based on these structural features, the possible structural basis of the functional properties of EAFP2 is discussed.

Amino Acid Sequence↗
PubMed1992

Universal access: its potential impact on emergency medicine.

The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional widsom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative primary-care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring high-quality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by third-party payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the pattern for several decades.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency Medicine↗
PubMed1994

Cardiac involvement in tuberous sclerosis.

OBJECTIVE: To assess the incidence, importance, and history of cardiac involvement in infants and children with tuberous sclerosis. DESIGN: Prospective study; clinical examination, sector and Doppler echocardiography, standard and ambulatory electrocardiography. SETTING: A tertiary referral centre. PATIENTS: 21 patients with tuberous sclerosis aged 1 day to 16 years (mean 6.3 years); follow up investigations were available in 14 cases (10 retrospective, 4 prospective; mean follow up 4.3 years). RESULTS: Multiple cardiac rhabdomyomas in the right ventricle (11) and left ventricle (14) as well as in the right atrium (1) were present in 14/21 patients. Two of them had obstruction of the left ventricular inflow and outflow tract related to a tumour. In the remaining 7 patients, echocardiography was normal in 4 and equivocal in 3 cases. The standard electrocardiogram (n = 20) showed ventricular hypertrophy (2), ventricular pre-excitation (1), arrhythmias (2), and repolarisation disturbances (4) in 7/13 patients with rhabdomyomas but was normal in all patients with a normal or equivocal echocardiogram. The ambulatory electrocardiogram (n = 19) showed frequent premature atrial (2) and polymorphous ventricular (2) contractions. The polymorphous ventricular contractions coexisted with rhabdomyomas. No arrhythmias that needed medical treatment were found. Follow up investigations showed return to a normal standard electrocardiogram in 3 patients. Definite regression or complete disappearance of the tumour occurred in 6 infants. CONCLUSIONS: Cardiac rhabdomyomas, although often present in these patients with tuberous sclerosis, caused neither major arrhythmias nor haemodynamic obstruction except in the neonatal period. The indication for operation is limited to cases with life threatening obstruction or arrhythmias refractory to medical treatment.

Adolescent↗
PubMedDate not supplied

Have structural adjustments led to health sector reform in Africa?

This paper explores the issue of whether and how structural adjustment in Sub-Saharan Africa has altered the level and nature of state involvement in the health care system. Stabilization and structural adjustment generally entail a reduction in aggregate demand, especially government spending, and a reduced role for the state in the provision of many goods and services. Consequently, there is an a priori concern that stabilization and adjustment in Africa may have resulted in lower health expenditures with deleterious effects on the health status of the population, particularly the poor. This paper concludes that structural adjustment programs in Africa did not reduce public health expenditures. In fact, many countries experienced higher real expenditures after adjustment. The fact that many indicators of health status deteriorated during the 1980s, however, presents somewhat of a paradox given the patterns of health expenditures. This paradox is resolved, by an investigation of the intrasectoral allocation of health expenditures which reveals that there are systematic biases in public expenditures towards tertiary and curative care, and a general weakness in the public sector's capacity to deliver adequate health care services even with higher real health sector budgets. In many countries, these biases have persisted despite government and donor intentions to promote health care reform. Finally, the paper reviews a set of policy and institutional issues which hinder the efficient use of budget resources, including overcentralization of health care administration, inappropriate drug and supply procurement practices, the lack of mechanisms for cost recovery, and poor organization, financial and personnel management. At each level of analysis, the paper catalogs those instances where progress is being made towards effective health care reform, including intrasectoral budget rationalization, administrative decentralization, the adoption of user fees for cost recovery, privatization in service delivery, particularly through non-governmental organizations, and organizational and management reform.

Africa South of the Sahara↗
PubMed1997

Hospitals in sub-Saharan Africa: why we need more of what does not work as it should.

This paper analyses the origins of today's crisis in the hospital sector in sub-Saharan Africa. Present trends in availability of hospital services are extrapolated to the future in order to provide a low-end estimate of the need for expansion of first referral level hospitals, This will not be possible without giving due priority to this sector, a commitment to considerable investments and reorientation of resources from tertiary to first referral level hospitals. It is to be feared that if this is not done, the backlog will increase, and, given the time lag before investments translate into operational services, there will be a major shortage of hospital services in sub-Saharan Africa within a decade.

Africa South of the Sahara↗
PubMed2004

Genetic services in Latin America.

This special issue of Community Genetics reviews some of the most important developments in medical genetics in key countries of Latin America. Contributions to this issue were prepared for a special consultation of the World Health Organization held in Porto Alegre, Brazil, on June 19, 2003. Latin America is a region of medium- to low-income countries characterized by socioeconomic problems, with large segments of the population living in poverty and extreme disparities in the distribution of wealth. A rise in chronic diseases typical of the processes of industrialization and urbanization coexists with the persistence of nutritional and infectious diseases characteristic of poverty and underdevelopment. Over the last 2 decades of the 20th century, birth defects and genetic disorders have increased their share of morbidity and mortality, and tertiary-care-based genetic services have developed in urban areas. Although privatization of health care is eroding the public sector, the public institutions continue to be the main providers of genetic services for the bulk of the population and the leaders in research. The development of clinical genetics in the region is concentrated in tertiary-care centers in large cities, although a recent trend began extending genetic services to the community.

Biomedical Research↗
PubMed2002

Health sector reform in South Asia: new challenges and constraints.

In early 1990s, Jamison, Mosley and others concluded that a profound demographic and consequent epidemiological transition is taking place in developing countries. According to this classical model, by the year 2015, infectious diseases will account for only about 20% of deaths in developing countries as chronic diseases become more pronounced. These impending demographic and epidemiological transitions were to dominate the health sector reform agenda in developing countries. Following an analysis of fertility, mortality and other demographic and epidemiological data from South Asian and other developing countries, the paper argues that the classical model is in need of re-evaluation. A number of new 'challenges' have complicated the classical interplay of demographic and epidemiological factors. These new challenges include continuing population growth in some countries, rapid unplanned urbanization, the HIV/AIDS pandemic in Sub-Saharan Africa (and its impending threat in South Asia), and globalization and increasing marginalisation of developing countries. While the traditional lack of investment in human development makes the developing countries more vulnerable to the vicissitudes of globalization, increasing economic weakness of their governments forces them to retreat further from the social sector. Pockets of poverty and deprivation, therefore, persist giving rise to three simultaneous burdens for South Asia and much of the rest of the developing world: continuing communicable diseases, increasing burden of chronic diseases, and increasing demand for both primary and tertiary levels of health care services. While these complex factors, on the one hand, underscore the need for health sector reform, on the other, they make the task much more difficult and challenging. The paper emphasizes the need to revisit the classical model of demographic and epidemiological transition. It is argued that the health sector in developing countries must be aware of and effectively address these 'new challenges'. Although it has included data from many developing countries, the focus is primarily on South Asia.

Bangladesh↗
PubMed2002

238U 226Ra 210Pb, 232Th and 40K activities in soil profiles of the Flysch sector (Central Spanish Pyrenees).

Distributions of natural gamma-emitting radionuclides were determined in three soil profiles developed on Tertiary sedimentary materials in mountain landscapes of the Central Spanish Pyrenees. Radioisotope activities (Bq kg(-1)) lie in the range of 0-53 for 238U; 19-33 for 226Ra; 7-75 for 210Pb; 24-48 for 232Th and 335-562 for 40K. 238U and 210Pb activities show an important variability down the soil profiles. 238U was markedly depleted in all upper soil layers and highly enriched in lower layers of two soil profiles. 210Pb exhibits very dissimilar distribution patterns in all three soils. 226Ra and 232Th had quite uniform depth distributions. 40K showed depletion in both upper and lower layers in one soil profile but remained fairly constant in the other two profiles. 238U/226Ra activity ratios (ARs) have been used to assess equilibrium in the 238U decay chain and as indicators of edaphogenesis in the studied soil profiles. Maintenance of initial proportionality in the ratio of 232Th/238U activities has been assessed through ARs of their progenies. Additionally, a variety of soil properties were measured down the soil profiles. Among soils, variation in radionuclide activies may be due to differences in carbonate content, organic matter and/or grain size. In this environment, soil properties differently affect mobilization of natural radionuclides. The association of some radiologic properties with soil layers suggest a relationship between soil processes and radionuclide distribution.

Journal Article↗
PubMed1997

A new trend in the study of low back pain in workplaces.

In 1996, the number of low back pain (LBP) cases totaled 5,162 in Japan, accounting for 60% of the total number of officially recognized cases of occupational diseases. In recent decades, the number of LBP cases, however, has been gradually decreasing. The rate of this decrease is slower in non-manufacturing industries than in other sectors, while the prevalence rate of LBP has tended to increase among workers in tertiary industries in 1995 and 1996. Epidemiological studies have clarified that workplace factors of LBP include not only the handling of heavy materials, but also unnatural postures, sudden and unexpected motions, and individual worker's characteristics. It was, therefore, suggested that comprehensive countermeasures to prevent LBP be undertaken on the basis of work environmental control, work management practice, and health care. The Labor Ministry of Japan issued guidelines for the prevention of LBP in 1994, in which various factors in the work environment, the importance of readiness for motion, standardization of work procedures, and exercise before work were newly outlined. In addition to the psychophysical and biomechanical models of LBP so far reported, established findings of physiological studies on muscle tone and postural reflexes have been conceptually introduced into the guidelines. Such physiological findings are essential for the mechanistic elucidation of work-related LBP and the preparation of its countermeasures, as LBP can also be caused by sudden and unexpected motions as well as various environmental factors. Physical and mental readiness to cope with changes in voluntary motions is a prerequisite for the prevention of LBP in daily work, which constitutes time-sequential changes in posture and motion under various environmental conditions. This paper critically reviews the workplace factors of LBP, its models for evaluating the workload on the body, and environmental risk factors with reference to the neural control of muscle contraction underlying the voluntary motion of workers.

Biomechanical Phenomena↗
PubMedDate not supplied

The impact of graduate education on the career paths of nurses.

This paper reports the findings of the first phase of a ten year longitudinal study of nurses graduating with higher degrees and diplomas. The higher education sector in Australia has been subjected to a variety of changes in the past decade. Amalgamations and restructuring, altered funding formulae, recognition of prior learning and credit transfer are some of the initiatives, many dictated by governmental bodies, which impact on the education system. Within this volatile context, graduate education in nursing has developed significantly in both quality and variety. These courses have been taken up vigorously by professionals who, until 1990, had limited opportunities for tertiary study in the discipline. Perhaps one of the most significant changes within education, and interestingly paralleled in the health sector, is the move to examine more carefully the outcomes of the process or service provided. The demographic profile, career movements and career plans of graduating students over a five year period from December 1992- December 1996 are presented.

Adult↗
PubMed1995

Diploma-prepared nurses' use of technological equipment in clinical practice.

Increasingly, nurses throughout the western world are receiving their educational preparation for initial registration in a tertiary environment at either the diploma or bachelor degree level. The length of time spent in the clinical setting has been reduced considerably, with the elimination of the apprenticeship system and the role of the student nurse as paid staff member. Concurrently, the amount of technological equipment used in the health care sector is both increasing rapidly and now found in general wards, not just the traditional 'high tech' environments. It is important to evaluate how well the tertiary experience prepares students in terms of their ability to handle common technological equipment such as infusion control devices or suction pumps. In the study reported here 245 diploma-prepared registered nurses completed a questionnaire designed to assess how nurses from tertiary institutions perceived their ability to handle technical equipment in the workplace. The majority of the respondents had been working for 7 to 12 months. No significant relationship was found between the frequency of use of specific items of clinical equipment and whether that item caused the nurse concern in practice. There was also no significant relationship between the frequency of use of an item and whether participants believed that competence should be acquired in relation to that item prior to tertiary graduation. Although moderate levels of comfort in the use of technical equipment were reported upon entry to the workplace, subjects rapidly acquired high levels of comfort in relation to equipment handling. The implications for hospital administrators and tertiary teaching programmes are discussed.

Adult↗
PubMed2004

Solution structure of Eucommia antifungal peptide: a novel structural model distinct with a five-disulfide motif.

The three-dimensional structure in aqueous solution of Eucommia antifungal peptide 2 (EAFP2) from Eucommia ulmoides Oliv was determined using (1)H NMR spectroscopy. EAFP2 is a newly discovered 41-residue peptide distinct with a five-disulfide cross-linked motif. This peptide exhibits chitin-binding activity and inhibitory effects on the growth of cell wall chitin-containing fungi and chitin-free fungi. The structure was calculated by using torsion angle dynamic simulated annealing with a total of 614 distance restraints and 16 dihedral restraints derived from NOESY and DQF-COSY spectra, respectively. The five disulfide bonds were assigned from preliminary structures using a statistical analysis of intercystinyl distances. The solution structure of EAFP2 is presented as an ensemble of 20 conformers with a backbone RMS deviation of 0.65 (+/-0.13) A for the well-defined Cys3-Cys39 segment. The tertiary structure of EAFP2 represents the first five-disulfide cross-linked structural model of the plant antifungal peptide. EAFP2 adopts a compact global fold composed of a 3(10) helix (Cys3-Arg6), an alpha-helix (Gly26-Cys30), and a three-strand antiparallel beta-sheet (Cys16-Ser18, Tyr22-Gly24, and Arg36-Cys37). The tertiary structure of EAFP2 shows a chitin-binding domain (residues 11-30) with a hydrophobic face and a characteristic sector formed by the N-terminal 10 residues and the C-terminal segment cross-linked through the unique disulfide bond Cys7-Cys37, which brings all four positively charged residues (Arg6, Arg9, Arg36, and Arg40) onto a cationic face. On the basis of such a structural feature, the possible structural basis for the functional properties of EAFP2 is discussed.

Amino Acid Sequence↗
PubMed2002

National disease management plans for key chronic non-communicable diseases in Singapore.

In Singapore, chronic, non-communicable diseases, namely coronary heart disease, stroke and cancer, account for more than 60% of all deaths and a high burden of disability and healthcare expenditure. The burden of these diseases is likely to rise with our rapidly ageing population and changing lifestyles, and will present profound challenges to our healthcare delivery and financing systems over the next 20 to 30 years. The containment and optimal management of these conditions require a strong emphasis on patient education and the development of integrated models of healthcare delivery in place of the present uncoordinated, compartmentalised way of delivering healthcare. To meet these challenges, the Ministry of Health's major thrusts are disease control measures which focus mainly on primary prevention; and disease management, which coordinates the national effort to reduce the incidence of these key diseases and their predisposing factors and to ameliorate their long-term impact by optimising control to reduce mortality, morbidity and complications, and improving functional status through rehabilitation. The key initiatives include restructuring of the public sector healthcare institutions into two clusters, each comprising a network of primary health care polyclinics, regional hospitals and tertiary institutions. The functional integration of these healthcare elements within each cluster under a common senior administrative and professional management, and the development of common clinical IT systems will greatly facilitate the implementation of disease management programmes. Secondly, the Ministry is establishing National Disease Registries in coronary heart disease, cancer, stroke, myopia and kidney failure, which will be valuable sources of clinical and outcomes data. Thirdly, in partnership with expert groups, national committees and professional agencies, the Ministry will produce clinical practice guidelines which will assist doctors and healthcare professionals to better manage important aspects of the key diseases. Finally, the Ministry has committed funds to support selected National Disease Management programmes, illustrated by the disease management plan for asthma.

Chronic Disease↗
PubMed1991

Missed opportunities for measles immunisation in selected western Cape hospitals.

Measles is still a major cause of childhood mortality and morbidity in South Africa. The World Health Organisation (WHO) has recently recommended that greater attention be paid to opportunities for immunisation in the curative sector. This study quantified the extent of missed opportunities for measles immunisation in children attending primary, secondary and tertiary level curative hospitals in the western Cape. Exit interviews of 1,068 carers of children aged between 6 and 59 months inclusive showed that 2.4-40.7% of carers had been requested to produce a Road-to-Health card, and that 4.8-43.1% of carers had a card available. The proportion of children with documented evidence of measles immunisation available ranged from 4.8% to 40.0% between facilities. The study demonstrated that a considerable number of potential opportunities to immunise children against measles are currently being missed in children attending hospitals and day hospitals in the western Cape. The study documents the effect of a fragmented approach to health care, and indicates a need for rapid integration of preventive and curative components of health care into a metropolitan-based primary health care service.

Child, Hospitalized↗
PubMed1990

Cardiac surgery for inmates in the Texas Department of Corrections.

All Texas prison inmates requiring hospitalization since 1983 have been transferred to a separate prison hospital adjacent to a tertiary care university hospital. We reviewed and analyzed the data regarding one major tertiary care service, namely cardiac surgery, to describe the rate of utilization of this service and its results. From January 1, 1984, to June 30, 1988, 73 inmates underwent 74 cardiac operations, 50 of which were coronary revascularizations. The age-adjusted rates of utilization for coronary artery bypass grafting were substantially higher for inmates over age 45 than for that described for the general population, whereas the utilization rates for valve surgery were comparable. There were no perioperative or late deaths, and 86% of the inmate patients are currently employed within the Texas Department of Corrections system or were employed at the time of their release. The utilization rates and the results of this representative tertiary medical care service for the state's prison population are comparable to those achieved in the private sector, and may have a substantial beneficial effect on inmate rehabilitation.

Adolescent↗
PubMed1983

Parallel structures in professional and folk health care: a model applied to rural Hati.

The paper argues that professional and folk sectors of pluralistic health care systems share certain structural features that in some respects have equal or greater importance than obvious differences. A model based on the concepts of primary, secondary and tertiary care is adapted to an analysis of both folk and professional domains of the rural Haitian health care system. Ethnographic and survey data are presented to support the position that underlying similarities are evident in patterns of cost, accessibility, specialization, recruitment and training of practitioners in both health sectors. The level of care model provides an analytic framework which gives proper attention to diversity in traditional healing, which is applicable to other health care systems, and which has relevance for the development of primary care resources in developing areas.

Adult↗
PubMed1998

Emerging issues in the antitrust definition of healthcare markets.

Managed care has shifted purchasing decisions from patients towards payers. While this shift has been associated with increased price competition in provider markets, we believe that it may enhance the potential for consumer injury from mergers in geographic markets previously considered immune to antitrust concerns (e.g. suburban components of large metropolitan areas). In addition, recent changes also increase concerns about mergers in product submarkets such as tertiary care.

Antitrust Laws↗
PubMed2002

Cardiovascular disease in Chinese Canadians: a case-mix study from an urban tertiary care cardiology clinic.

BACKGROUND: Cardiovascular diseases (CVD) are the leading cause of death in Canada. Non-European ethnic groups such as the Chinese constitute an increasingly significant sector of the Canadian population. OBJECTIVE: To compare the frequency and risk factors of CVD in Chinese and white Canadians in a cardiology referral clinic that saw a high number of ethnic Chinese patients and provided equal access to advanced diagnostic facilities. PATIENTS AND METHODS: Clinic charts of patients referred between 1994 and 1999 were reviewed. Patients of Chinese descent were identified by their names. Primary cardiovascular and secondary cardiovascular diagnoses, as well as risk factors for coronary artery disease (CAD), were established. The frequency of disease and risk factors were age-standardized. RESULTS: The sample of patients with CVD consisted of 404 Chinese and 1129 white subjects. Chinese patients were older (median age 65 versus 62 years, P=0.006). CAD, heart failure and peripheral vascular disease were less frequent in Chinese than in white patients. On the other hand, valvular heart disease was more frequent in Chinese patients. Diabetes, smoking and family history of heart disease were less frequent in Chinese subjects, whereas the frequencies of hypertension and hypercholerolemia were similar to those of white patients. In patients who had undergone coronary angiography, the frequency of multivessel CAD was less in Chinese patients (40% versus 56%, P=0.0016). Angina pectoris was a more common manifestation of CAD in Chinese patients, whereas myocardial infarction was more common in people who were white. In patients with heart failure, the median left ventricular ejection fraction was higher in Chinese than in white patients (34% versus 28%, P=0.031). CONCLUSIONS: In patients referred to a cardiology clinic, the diagnosis of CAD and the majority of other CVDs was less frequent in Chinese Canadians than in white Canadians. However, selected modifiable risk factors for CAD, such as hypertension and hypercholesterolemia, were equally frequent. Further research at the population level is warranted to define the characteristics of CVD in Chinese Canadians, and may be useful to the future design of disease management and prevention programs tailored to the needs of this growing ethnic population.

Aged↗