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PubMedDate not supplied

Training for general practice: a look to Norway.

In the 1960s general practitioners were a dying race in Norway. Today general practice is a highly approved specialty among doctors as well as patients. Better education is one of the revitalizing factors. General practice is currently taught as a mandatory subject at all four universities in Norway. The practice apprenticeship is the essential element in our undergraduate curricula. In their fifth year, the students spend three to eight weeks in a structured training program supervised by general practice faculty. Approximately 500 general practitioners take part in this decentralized training network. In 1985 general practice was recognized as a specialty in Norway. The obligatory requirements in the five-year educational program are: -courses, 400 hours -hospital training, one year -general practice training, four years -group-based training program, two years The last element is based on a decentralized concept where a group of two to 10 trainees meet for three hours every two weeks during a two-year period. The group is headed by an appointed and qualified trainer. Besides being in accordance with the geography and demography of Norway, this model gives substance to the slogan "general practice can only be learnt in general practice."

Curriculum↗
PubMed1985

Sensitivity changes in the smooth muscle of the guinea-pig isolated vas deferens after treatment of animals with 6-hydroxydopamine.

Postjunctional supersensitivity of the smooth muscle of the guinea-pig vas deferens induced by denervation, decentralization and treatment of animals with reserpine has been attributed, in part, to a partial membrane depolarization (8-10 mV) resulting from reduced electrogenic Na+,K+-pumping activity. This study was undertaken to characterize sensitivity changes which occur after treatment of animals with 6-hydroxydopamine (100 mg/kg + 250 mg/kg i.v., 1 day apart). Seven days after the second injection, concentration-response curves for isometric contractile responses to norepinephrine, methoxamine, acetylcholine and histamine were shifted 40.6-, 1.7-, 3.6- and 2.7-fold, respectively, to the left of control; however, the sensitivity to KCl was not increased, which contrasts with the results after denervation, decentralization and reserpine treatment. Ouabain (10(-5) M) produced 1.8- and 1.3-fold leftward shifts of the KCl concentration-response curves in tissues from control and 6-hydroxydopamine-treated animals, respectively. The pronounced effect of ouabain in tissues from treated animals may be an indication that 6-hydroxydopamine treatment does not result in as much inhibition of electrogenic Na+,K+-pumping, and resultant membrane depolarization, as other methods which induce supersensitivity of the guinea-pig vas deferens.

Acetylcholine↗
PubMed1988

Co-release and functional interactions of neuropeptide Y and noradrenaline in peripheral sympathetic vascular control.

1. The immunohistochemical results suggest that NPY-LI co-exists with NA in sympathetic periarterial nerves of skeletal muscle. The corresponding veins are associated with few or no sympathetic nerves. 2. SNS evoked a detectable overflow of NPY-LI from the dog gracilis muscle in vivo during high-frequency but not low-frequency stimulation. After the administration of alpha-adrenoceptor antagonists, the overflow of NPY-LI was enhanced, indicating prejunctional inhibition of release via a mechanism similar to that for NA. Reserpine pretreatment depleted both NA and NPY-LI from skeletal muscle. The reserpine-induced depletion of NPY-LI, but not of NA, was highly dependent on intact nerve activity, since it was prevented by decentralization. 3. Slowly developing and long-lasting vasoconstriction was evoked by exogenous NPY and by high-frequency SNS in the gracilis muscle in the presence of adrenoceptor antagonists that completely blocked the vasoconstrictor response to exogenous NA. After reserpine treatment, considerably larger vasoconstrictor responses to SNS were observed in the decentralized muscle than in the intact one, in parallel with the overflow of NPY-LI. These results suggest that the released NPY may be the mediator of the adrenoceptor antagonist- and reserpine-resistant functional responses to SNS in the gracilis muscle. ATP mechanisms seem to be of less importance for the sympathetic control of gracilis muscle vasculature. 4. The plasma levels of NPY-LI and NA in man increased during physical exercise, suggesting a co-release from sympathetic nerves. This release appears to be attenuated by activation of alpha-adrenoceptors since phentolamine and clonidine, respectively, enhanced and suppressed the exercise-induced increase in the plasma levels of both NPY-LI and NA. The plasma levels of NPY-LI were increased during control conditions, and altered by clonidine and phentolamine, mainly at high work loads, which may indicate preferential release of the peptide at high levels of sympathetic activity. 5. Local i.a. infusion of NPY in man reduced forearm blood flow with a threshold effect at a plasma concentration in the low nmolar range. The reduction in forearm blood flow induced by NPY was considerably more long-lasting than that evoked by NA, which may partly be related to the long metabolic half-life of NPY. 6. NPY induced contractile effects in vitro that varied between different arteries and veins. The most pronounced effects were evoked in small human skeletal muscle arteries, where NPY caused a maximal contraction similar to that of NA.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1986

Effect of pharmacists' clinical interventions on nonformulary drug use.

The effect on drug costs of pharmacists' interventions in reducing the use of nonformulary medications was studied in a private teaching hospital. During a four-month period, nonformulary medication request forms and pharmacist consultation logs were reviewed to determine physicians' actions taken on requests for nonformulary medications. Cost avoidance of interventions (nonformulary medication cost) and the cost of pharmacist cost) and the cost of pharmacist time for the interventions were determined. The pharmacist was able to contact The pharmacist was able to contact the physician in 388 of 394 instances in which the use of a nonformulary medication was considered. Of 230 recommendations by pharmacists to change a nonformulary drug order to one for a formulary alternative, 64.8% (149) were accepted by physicians. Of pharmacists' recommendations that were accepted, 75.8% (113/149) were from decentralized areas, which was a significantly higher acceptance rate than that for the centralized areas (24.7% or 36/149). Cost avoidance resulting from acceptance of pharmacists' recommendations during the four-month study was $2,645, or $13,573 per year; this was more than the cost of pharmacist time required to perform interventions. Pharmacist interventions to decrease use of nonformulary drugs can be cost-effective and appear to be more successful in decentralized pharmacy service areas than in areas served by a central pharmacy.

Costs and Cost Analysis↗
PubMed1985

Prospective-pricing strategies for hospital and departmental effectiveness: the physician's response.

Physician-practice patterns are discussed, and programs of decentralization designed to reduce ancillary use are described. The New England Medical Center (NEMC) conducted a study with two other major hospitals in Boston comparing physician-practice patterns for patients who had had carotid endarterectomies. The indications for surgery for these patients did not appear to be different among the hospitals; however, average charges and length of stay varied considerably. Operating-room time and postoperative management also varied substantially. Strategies to change physician-practice patterns must address the issues of incentives to physicians and hospitals. At NEMC, a program of decentralization is being implemented that involves physician participation in budgeting hospital resources. A program of product pricing has been developed, whereby the NEMC offers an HMO a fixed price for certain kinds of cases upon admission. A daily use report was started to report resource use for specific cases compared with annual medians for that type of case. Case types from many different surgical specialties are involved. The reports show physicians the difference between the actual and expected costs in terms of variances. The NEMC has reoriented its budgeting process to include clinical divisions. Clinical services are planning to budget the use of intermediate products across different cost centers. The clinical budgeting program makes the planning process more objective, lowers the use of ancillary services, and reduces costs.

Ancillary Services, Hospital↗
PubMed1979

Influence of neuronal activity levels on the cytotoxic effects of guanethidine.

Reduction of activity levels in the noradrenergic innervation of the iris of the rat by decentralization of the superior cervical ganglion resulted in a marked increase in sensitivity of these fibers to damage by chronic guanethidine treatment (15 mg/kg/day) as shown by fluorescence histochemistry. Guanethidine also had an increased cytotoxic effect on the decentralized nerve cell bodies. These results suggest that the relative inactivity of male "short" noradrenergic neurons may contribute to their sensitivity to damage by guanethidine. The nature of the damage produced in other tissues by this dose of guanethidine indicates that levels of neuronal activity are not the only factor determining sensitivity to the cytotoxic effects of this drug.

Animals↗
PubMed1969

The biomedical communications network.

The Biomedical Communications Network (BCN) is the embodiment of the plans of the National Library of Medicine to provide improved information, document, and education services to the health community. The BCN also will be the "core" public service network to ensure the most expeditious delivery of health information and education products to a selected public. As such, utilization of communications satellites as well as other more common forms of telecommunications are planned. The library component of the Network will provide decentralized library services to medical libraries, medical schools, hospitals, MEDLARS Centers, local medical centers and individual medical practitioners. These decentralized services will be provided through an information network with its hub at the Bethesda, Maryland site of the NLM. The NLM intends that the library services network be a controlled rather than a permissive system. This simply implies that participation and access to the services of the system will be determined by the NLM. Planning has already progressed to the point where services to be provided can be enumerated.

Communication↗
PubMed1966

The MEDLARS regional center at UCLA: a progress report.

This paper supplements information given in earlier papers on the UCLA MEDLARS Search Station. Four major machine problem areas in the operation of a decentralized station are identified: adjustments required to run a large information retrieval type program in an academic computing facility serving many users; handicap in running time for COBOL programs; advent of the third generation of computers with attendant preparation; and need for constant current communication among all members of a decentralized network system. Statistics are given for the initial operating period, January-May 1966: 119 search requests received, 109 formulated, and 60 fully processed. Parallel searches with other MEDLARS installations, comparisons of MEDLARS and manual Index Medicus searches, and other search activities are reported.

California↗
PubMed1984

Sympathetic reinnervation of the pineal gland after postganglionic nerve lesion does not restore normal pineal function.

The activity of the enzyme serotonin N-acetyltransferase (NAT) in the rat pineal gland exhibits a large circadian rhythm, with peak activity occurring at night. This rhythm is dependent on stimulation of the pineal gland by neurons whose cell bodies are in the superior cervical ganglia and whose axons reach the gland via the internal carotid nerves (ICNs). Two days after both ICN were cut, crushed, or frozen, nighttime NAT activity was decreased by 90%. The remaining low level of enzyme activity was not affected by decentralization of the superior cervical ganglia. Thus, this enzyme activity did not depend on the activity of neurons in these ganglia. Bilaterally lesioning the ICN also abolished the neuronal uptake of norepinephrine in the pineal, further indicating that the sympathetic innervation of the gland had been destroyed. Three months after crushing both ICNs, nighttime NAT activity was only 20% of control values. However, in these animals, bilateral decentralization of the superior cervical ganglion reduced this low level of NAT activity by 90%. Thus, NAT activity, although low, was again dependent on sympathetic nerve stimulation. In contrast to this rather small recovery of nocturnal NAT activity, the norepinephrine uptake capacity of the gland recovered to 60% of control values. A similar discrepancy between the extent of recovery of NAT activity and of norepinephrine uptake was observed when the ICNs were frozen rather than crushed. To determine to what extent the sympathetic nerves that had reinnervated the pineal gland in these lesioned animals were capable of regulating NAT activity, their cervical sympathetic trunks were stimulated electrically at 5 Hz for 3 hr during the daytime.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetyltransferases↗
PubMed1984

Antineoplastic admixture service in a tertiary-care hospital.

The rationale and decision-making processes involved in the development and implementation of an antineoplastic admixture service in a 1027-bed teaching hospital are described. Because of concerns expressed by nurses about the potential health hazards of handling antineoplastic drug products, the department of pharmacy was asked to prepare all injectable antineoplastic agents within the institution. At the time of the request, the pharmacy department operated 12 decentralized pharmacies and one central pharmacy; no i.v. admixture services were provided, except for total parenteral nutrient solutions. In developing the service, the pharmacy department considered the advantages and disadvantages of (1) a centralized versus decentralized organization, (2) various physical facilities, and (3) various staffing patterns. An ad hoc committee of the P & T committee was formed to develop multidisciplinary guidelines for the appropriate handling of these products. A centralized service open from 0800 to 1600 daily was established. A supervisor was hired to train and manage the rotation of the entire pharmacy staff through the area. A vertical laminar-airflow biologic safety cabinet and exhaust adapter were purchased, and policies and procedures for handling the antineoplastic agents were developed for all involved personnel. Since opening in July 1983, the antineoplastic admixture service has been positively received by health-care providers in this institution, and no major problems have been associated with the program.

Antineoplastic Agents↗
PubMed1981

Part I. Seg insect for the "executive" multifocal. (Or it really can be done the way you want it).

Design principles of the one-piece Franklin type bifocal are described and illustrated. Correct (and incorrect) methods for verifying decentration are explained. Examples of typical decentration problems are given as well as explicit instructions for telling the lab how to lay out the blank for surfacing. A formula for determining the maximum frame/lens size that will cut out of a given blank is provided.

Eyeglasses↗
PubMed1981

[Trophic and functional changes of the pancreas induced by chronic truncal vagotomy].

The effects of chronic truncal vagotomy on the pancreatic gland was studied in male adult Wistar rats. Two to three months after parasympathetic decentralization, the gland weight was found to be significantly increased by nearly 100%. This trophic effect is mainly due to the proliferation of young acinar cells. Concomitantly, there is a decrease of the ductular mass and of the Langerhans islets. Choline acetylase activity was decreased by about 35% to 40% in the vagotomized pancreas. Further, enzyme concentration was found to be greater in the head than in the body and tail of the gland, thus suggesting a higher nerve density of vagal cholinergic fibers in the former than in the latter. Basal pancreatic secretion of the decentralized gland showed a significant increase in the flow rate with no significant changes in both bicarbonate concentration and output. Protein concentration was significantly reduced at 60 minutes; protein output remained unchanged. The most remarkable finding was the fall in both lipase concentration and output (60-70%) when compared with control values. These findings may be related to clinical manifestations after long-term vagotomy.

Animals↗
PubMed1995

Managed health care. Managing the risks of laboratory testing in an integrated delivery system.

Decentralized testing must be viewed as a component of the decentralized patient care that is prevalent today. It cannot be considered a separate component of the total laboratory process, but must be examined in the context of test ordering and test performance through test result disposition and use. The evolving configuration of the health-care delivery system necessitates a redefinition of risk to include four categories of risk: business, financial, insurable, and clinical quality. Reengineering the clinical laboratory process in today's health-care environment needs to incorporate all these risk issues, systems thinking, and available technology along with the changing practice of medicine.

Delivery of Health Care↗
PubMed1995

Alternate site testing. The old and new paradigm or the past is prologue.

This paper reviews broad themes emerging in the discussion concerning alternate site testing, including the emergence and continuing value of centralized testing, the reasons for alternate site testing, and the relative merits and negative aspects of traditional centralized testing and decentralized models. The paper attempts to identify the expectations of constituencies affected by alternate site testing (patients, physicians, nurses, administrators and managers, and pathologists and other laboratory professionals) and identifies criteria and implementation strategies for decentralized testing.

Centralized Hospital Services↗
PubMedDate not supplied

Evaluation of night vision disturbances.

BACKGROUND: Evaluation of night vision disturbances has relied on subjective responses. We designed a test to more objectively measure night vision disturbances. METHODS: The test consisted of projecting a small circle onto a visual acuity screen. The patient is asked to draw exactly what he sees on an Amsler grid. We evaluated 118 eyes in photopic and scotopic conditions and under different conditions of refractive correction. RESULTS: Image degradation increased in scotopic conditions for myopes (p = .0001), hyperopes (p = .005), and emmetropes (p = .01). Myopic refractive error correlated with size of glare response (p = .001). Astigmatism correlated with decentration of glare response (p = .0001). Decentration increased in scotopic compared to photopic conditions (p = .002). CONCLUSION: Our test offers a simple, convenient way to evaluate night vision disturbances and may offer a means of assessing night vision disturbances in patients considering refractive surgery.

Adolescent↗
PubMed1978

[Rabies prevention at Cap-Bon (Tunisia) from 1973 to 1977].

During the period 1973-1977, decentralization of our rabies preventive program has been carried out. Three times more people attended our clinics without affecting the quality of routine care in each centre. Decentralization of an activity in a Public Health District can be used as a way of integrating curative and preventive activities. Five criteria are defined for supervision of this activity by the district doctor in charge.

Adolescent↗
PubMed1993

[Serum screening of pregnant women for fetal neural tube defects and Down syndrome; initial experiences in The Netherlands].

OBJECTIVE: To examine if, and if so, in what way, the maternal serum screening for fetal neural tube defects (NTD) and Down's syndrome (DS) in the Dutch decentralized obstetrical organization would be feasible and effective. DESIGN: Prospective. SETTING: University Hospital Groningen. METHOD: Between October 1st 1990 and December 1st 1991 we determined the likelihood of a baby with a NTD and/or DS in 2580 pregnant women, at 15 to 20 weeks gestation, by serum screening. RESULTS: Five foetuses with DS were detected, as well as two with a NTD, one foetus with an omphalocele, and one with Turner's syndrome. One infant with a NTD and one with DS were not found prenatally. Of all 98 women of 36 years or older, 68 declined amniocentesis because their risk was lower than the age related risk. CONCLUSIONS: Maternal serum screening for NTD and DS is feasible and effective in principle. In a decentralized prenatal care system, special attention has to be paid to the time needed to report the results and to the completion of the follow-up. The detection rate of DS in pregnant women of 36 years or older remains almost the same, but a significant number of them decline prenatal diagnosis. An increased risk of foetal DS, determined by serum screening, should be added to the official list of indications for prenatal diagnosis in the Netherlands.

Adolescent↗
PubMed1995

The Citadel cannot hold: technologies go outside the hospital, patients and doctors too.

Use of the acute hospital has markedly decreased over the past four decades for various reasons: the decentralization of diagnostic treatment technologies to out-of-hospital sites; the clinical substitutions of quick diagnostic testing of the ambulatory patient for the longer diagnostic testing of the hospitalized patient; the diminished use of hospital bed rest and the expanded use of exercise for treatment; the corporate organization of hospital work that emphasizes efficiency; and the group practice organization of generalists and specialists that avoids hospital use for the diagnosis of complex disorders in ambulatory patients. A smaller domain for hospital bed care and renewed attention to chronic disease and prevention in the community diminish the hold of the acute hospital on care. The evolution of more collaborative, decentralized arrangements promises to be a positive development for community care.

Ambulatory Care↗