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PubMed2006

Health information exchange on a regional level: dream or reality?

Cooperation between healthcare institutions on the subject of Information Technology in Healthcare is an important main objective in the region Delft Westland Oostland/Nieuwe Waterweg Noord, in the mid-western part of the Netherlands. This is a densely populated area with approximately 1 million inhabitants. In 2004 a project to uniquely identify patients was initiated. The aim was to build a Regional Referral Index, containing only general patient data, which knows where patient information resides, serving as the fundament of a regional Virtual Electronic Patient Record. Initially the Regional Referral Index was filled with the patient files from two hospitals in the region. A connection was made between the Regional Referral Index and the Hospital Information Systems. Since then, the Regional Referral Index has been updated automatically. The patient files have been tested and matched in order to obtain a 'clean' patient index. Since December 2005 the Regional Referral Index is operational and ready for further developments. Precautions are taken to guarantee patient privacy and security of data. Only authorized users will be given access to patient data. Administration and maintenance of this Regional Referral Index is arranged by establishing a Patient Information Point. Currently, patient files of the other care providers in the region are being added and pilot projects to accomplish access to medical patient information are being realised. The regional activities run parallel and in line with national initiatives, aiming to link up with these initiatives over time.

Confidentiality↗
PubMed2002

[Tuberculosis in Asia].

1. Philippines: The development, expansion and maintenance of pilot area activities: Cristina B. Giango (Technical Division, Cebu Provincial Health Office, the Philippines) In 1994, the Department of Health developed the new NTP policies based on WHO recommendations and started a pilot project in Cebu Province in collaboration with the Japan International Cooperation Agency. To test its feasibility and effectiveness, the new NTP policies were pre-tested in one city and one Rural Health Unit. The test showed a high rate of three sputum collection (90%), high positive rate (10%), and high cure rate (80%). Before the new guidelines were introduced, the new policy was briefed, a baseline survey of the facility was conducted, equipment was provided, and intensive training was given. Recording/Reporting forms and procedures were also developed to ensure accurate reporting. Supervision, an important activity to ensure effective performance, was institutionalized. Laboratory services were strengthened, and a quality-control system was introduced in 1995 to ensure the quality of the laboratory services. With the implementation of DOTS strategy, barangay health workers were trained as treatment partners. In partnership with the private sector, the TB Diagnostic Committee was organized to deliberate and assess sputum negative but X-ray positive cases. The implementation of the new NTP guidelines in Cebe Province has reached a satisfactory level, the cure rate and positive rate have increased, and laboratory services have improved. Because of its successful implementation, the new NTP guidelines are now being used nationwide. 2. Nepal: The DOTS Strategy in the area with hard geographic situation: Dirgh Singh Bam (National Tuberculosis Center, Nepal) Three groups of factors characterize the population of Nepal: 1) Socio-cultural factors, e.g. migration, poverty, language; 2) Environmental factors, e.g. geography and climate; and 3) Political factors, prisoners and refugee populations. These factors pose particular problems for implementing DOTS in various ways. Socio-cultural and environmental factors are particularly important in Nepal, and several measures have been developed to overcome these difficulties. One is active community participation through the DOTS committee. The committee consists of a group of motivated people, including social workers, political leaders, health services providers, journalists, teachers, students, representatives of local organizations, medical schools and colleges, industries, private practitioners, and TB patients. One DOTS committee is formed in every treatment center. A key role of the DOTS committee is to identify local problems and their solutions. It increases public awareness about TB and DOTS; supports people with TB in the community by providing treatment observers and tracing late patients; and encourages cooperation among health institutions, health workers, NGOs, and political leaders. The case finding rate is now 69%, and nearly 95% of diagnosed TB cases are being treated under DOTS. The treatment success rate of new smear-positive cases is nearly 90%. Thus, DOTS increases the case finding and treatment success. 3. Cambodia: HIV/TB and the health sector reform: Tan Eang Mao (National Center for Tuberculosis and Leprosy Control, Cambodia) Cambodia is one of the 23 high burden countries of tuberculosis in the world. Moreover, HIV/AIDS has been spreading rapidly since 1990s, which is worsening the tuberculosis epidemics. To cope with the burden, Cambodia has started implementation of DOTS in 1994 and has expanded it to most of public hospitals across the country by 1998. NTP of Cambodia is now enjoying high cure rate of more than 90%. However, due to the constraints such as weak infrastructure and the poverty, it is proved that many of TB sufferers do not have access to the TB services, resulting in still low case detection rate. It is for this reason that the NTP has decided to expand DOTS to health center and community level based on the new health system. Its pilot program that has been carried out in collaboration with JICA and WHO since 1999 has achieved promising results with high detection and cure rates. All of the over 900 health centers across the country will be involved in DOTS strategy by 2005. In the fight against TB/HIV, National Center for TB Control is providing free TB screening for PLWH (people living with HIV/AIDS), and it is developing a comprehensive plan of TB/HIV care including home delivery DOT services. 4. China: The World Bank Project and the Prevalence Survey in China: Hong Jin DuanMu (National Tuberculosis Control Center, China) Since 1992, China has utilized a World Bank loan to implement TB control projects among 560 million people in 13 provinces. Free diagnosis and treatment services have been provided to all patients, and a fully supervised standard short-course chemotherapy was applied to all diagnosed tuberculosis patients. In 1999, more than 190,000 smear-positive cases, ten times the number in 1992, were detected, and the registration rate of new cases reached 30 per 100,000 population. From 1992 to 1999, a total of 1.40 million smear-positive TB patients were discovered. The cure rate of smear-positive TB patients has been improved to an overall cure rate of 93.6%. The cure rates for the new cases and re-treatment patients were 95.1% and 89.6%, respectively. The fourth nationwide random survey for the epidemiology of tuberculosis was conducted in 2000. The prevalence of active tuberculosis was 367/100,000, the prevalence of infectious tuberculosis was 160/100,000, and the prevalence of smear-positive tuberculosis was 122/100,000. The tuberculosis mortality was 9.8/100,000. 5. Vietnam: The road to reaching the Global Target: Le Ba Tung (Pham Ngoc Thach Tuberculosis and Lung Disease Center, Vietnam) TB control activities started in 1957 and were reorganized in 1986 with the technical assistance of IUATLD, KNCV and material assistance of Medical Committee Netherlands Vietnam (MCNV). The New National TB Control Program follows the main directives of WHO and IUATLD's procedures of case-finding, chemotherapy and management. Passive case-findings are based on sputum smear. Chemotherapy with priority for smear positive cases is 3SHZ/6S2H2 for new cases and 3HRE/6H2R2E2 for retreated cases, which is undertaken with directly observed therapy (DOT strategy) mainly at commune health posts. Since 1989, DOTS strategy with 2SHRZ/6HE for new cases and 2SHRZE/1HRZE/5H3R3E3 for retreated cases has gradually been introduced in districts and communes of every province. In 1995, the government established the National and Provincial TB Control Steering Committees and has provided incentives for detected smear positive cases and cured smear positive cases. The government has also started strengthening the program of managerial and supervisory capacity for TB staff and has promoted the cooperation of all associated organizations of TB control. The WHO global surveillance and monitoring project reports that in 2000 Vietnam reached the global target, i.e., 99.8% population covered by DOTS with 80% of expected new smear positive cases being detected and a high cure rate ranging from 85.3% in 1989 to 90.3% in 1999. A distinguishing aspect of TB control in Vietnam is the effective international partnerships combined with high political commitment of the government nationally and provincially as well as active participation of all organizations in the community.

Asia↗
PubMed2003

American Society of Clinical Oncology policy statement: oversight of clinical research.

UNLABELLED: Well-publicized lapses in the review or implementation of clinical research studies have raised public questions about the integrity of the clinical research process. Public trust in the integrity of research is critical not only for funding and participation in clinical trials but also for confidence in the treatments that result from the trials. The questions raised by these unfortunate cases pose an important opportunity to reassess the clinical trials oversight system to ensure the integrity of clinical research and the safety of those who enroll in clinical trials. Since its inception, the American Society of Clinical Oncology (ASCO) has worked for the advancement of cancer treatments through clinical research and to help patients gain prompt access to scientifically excellent and ethically unimpeachable clinical trials. As an extension of its mission, ASCO is affirming with this policy statement the critical importance of a robust review and oversight system to ensure that clinical trials participants give fully informed consent and that their safety is a top priority. Ensuring the integrity of research cannot be stressed enough because of its seminal connection to the advancement of clinical cancer treatment. The overall goal of this policy is to enhance public trust in the cancer clinical trials process. To achieve this, the following elements are essential: 1. Ensure safety precautions for clinical trial participants and their fully informed consent. 2. Ensure the validity and integrity of scientific research. 3. Enhance the educational training of clinical scientists and research staff to ensure the highest standards of research conduct. 4. Promote accountability and responsibility among all those involved in clinical research (not just those serving on institutional review boards [IRBs], but also institutional officials, researchers, sponsors, and participants) and ensure support for an effective oversight process. 5. Enhance the professional and public understanding of clinical research oversight. 6. Enhance the efficiency and cost-effectiveness of the clinical research oversight system. This policy statement makes recommendations in several areas that serve as principles to support an improved system of oversight for clinical research. ASCO will work with all parties involved in the clinical research system to develop the steps necessary to implement these recommendations. Centralized Trial Review: A large percentage of oncology clinical trials are coordinated through the National Cancer Institute's (NCI) system of cooperative groups, which already incorporates centralized scientific review. As such, there is a tremendous opportunity to employ a centralized mechanism to provide ethical review by highly trained IRB members, allowing local IRBs to take advantage of the financial and time efficiencies that central review provides. Centralized review boards (CRBs) would also contribute consistency and efficiency to the process. Once successfully completed, the review would represent an approval to open the protocol at all of the institutions that have subscribed to the centralized review system. Local IRBs would be able to devote time usually spent on initial review to ongoing monitoring of the trial taking place at their institution. Considering the enormous size and complexity of the clinical research enterprise, ASCO envisions multiple CRBs, which could be distributed as regional review boards. Central review will use a single protocol and consent form, and monitor and evaluate adverse events (AEs) on a global basis, eliminating many of the time-consuming steps for the local IRB. Global monitoring and assessment of AEs has real potential to enhance trial participants' safety by giving local institutions more information on the overall trial and enabling them to devote more time to ongoing review of the trial onsite. Use of a CRB also has real potential to reduce the costs of clinical trial oversight by allowing local IRBs to eliminate the costs of initial review. These efficiencies will likely lead to institutions redirecting funds toward monitoring ongoing trials. Although a CRB has potential to improve the efficiency of the process, a CRB could also have tremendous ability to delay valuable trials. Checks and balances must be included in the newly devised system to ensure timely review and appeals of CRB actions. ASCO proposes the advent of a new pilot program for centralizing review of clinical trials. It requires clear engagement of all stakeholders in planning the experiment, clear articulation of the goals, and assurance of federal regulatory protection for institutions choosing to participate. If successful, this CRB pilot project could be expanded to include multi-institutional industry-sponsored research. Education and Training:Education and training are critical to the ultimate success of an improved oversight system. All members of the research team should receive comprehensive education on conducting scientifically and ethically valid clinical research. The curriculum should also include information on the prevailing local and federal regulations that pertain to the clinical trials process. IRB members should also receive ongoing education and training in the review of clinical research protocols. IRB training should pay particular attention to nonscientific members to give them the tools necessary to speak on behalf of research participants. ASCO should develop a curriculum that focuses on the proper conduct of human research and emphasize ethically sound clinical research in the context of its Annual Meeting. Informed Consent: Investigators and review boards have specific roles to play in ensuring the education of trial participants through the informed consent process, both when they are considering trial enrollment and as they participate in the trial. Review boards and investigators should focus primarily on the informed consent process, rather than the informed consent documents. Federal Oversight: The federal government has an important role to play in the oversight of clinical research. This role should be expanded to cover all research, not just that which is funded by the federal government or conducted with the oversight of the Food and Drug Administration (FDA). The Department of Health and Human Services (HHS) Office for Human Research Protections (OHRP) and the FDA should provide clear regulatory support and guidance for local institutions that choose to employ a CRB. In the case of the pilot CRB discussed in this policy statement, it should serve as the preferred option for the cancer cooperative group clinical trials. Ideally, the federal government should unify and streamline its regulations for the oversight of clinical research. Resources Supporting Clinical Research Infrastructure:An effective oversight process demands the highest quality scientific and ethical review and onsite monitoring of the safety of trial participants. This can only be accomplished by the involvement of an experienced IRB that receives funding, resources, and institutional support enabling it to fulfill its mandate. CONFLICT OF INTEREST: Critical to the integrity of research is the absence of bias in the process. ASCO strongly recommends the adoption of standards for the identification, management, and, where appropriate, elimination of conflicts of interests, whether they are actual, potential, or apparent.

Biomedical Research↗
PubMedDate not supplied

Comparing women's assessment of midwifery and medical care in Québec, Canada.

In 1990, the province of Québec, Canada, adopted a law that authorized the evaluation of the practice of midwifery through pilot projects before its legalization. A key objective of this evaluation, as defined by the law, was the documentation of women's assessment of maternity care, especially with regard to humanization and continuity of care. Two to 3 months after birth, 933 midwifery clients and 1,000 physicians' clients, matched on several characteristics, responded to a mailed questionnaire (response rates were 93% and 76%, respectively). Results showed that women from both groups were generally satisfied with the care they received, although women who received midwifery care were assessed as more positive on every issue surveyed. Objective measures supported impressions that were also confirmed through qualitative data analysis: midwifery clients had a greater number of and longer prenatal visits, their care was perceived to be more personalized, and a greater number of midwives' clients breastfed their infants. However, the interpretation of these results must take into account that the two groups had different personal expectations and values with regard to health and health care. These findings are enlightening in evaluating women's needs, expectations, and satisfaction with health care services and should be included in future development of maternity care, including idwifery services, in Québec and other locations.

Cohort Studies↗
PubMed1999

Experienced nurses learning with medical students: a case study.

Although there are successful examples of interdisciplinary education this generally relates to pre-registration health-care professionals. Post-registration projects are usually confined to skills workshops or social science subjects, which rarely include medical staff. This project was unusual in its attempt to combine the needs of experienced practitioners with those of medical students. There are practical issues for this form of learning such as, the organization of modules into 'systems' when health-care professionals (as part of a parallel project) indicated their interests lay in courses that related to clinical practice organized around disease processes/conditions. This case study demonstrates that concerns related to the potential mismatch of clinical expertise, maturity and scientific background are not insurmountable problems, and that clear benefits can be gained. It could be argued that until pre- and post-graduate medical staff are integrated with other disciplines, the real benefits of shared understanding, enhanced team work and mutual respect will remain illusive. It is not anticipated that this form of learning would be suitable for the majority of practitioners, whose core needs are generally met by existing opportunities. However, there is a need for a greater depth of academic understanding particularly for those in senior positions or in specific specialized areas (also identified in the parallel study) and for those whose roles are expanding. These practitioners are more likely to have the ability to apply their new knowledge to clinical practice, using reflective techniques with minimal facilitation to enhance their established clinical expertise. For them this model of learning offers the opportunity to tailor education to the individual needs of the practitioner without the costly establishment of complete new programmes of learning. This case study proved particularly successful for the participants as they enhanced understanding and confidence in the knowledge underpinning their practice. This enabled them to better anticipate patients needs, to identify complications and initiate action at an earlier stage. Their appreciation of rationale underpinning medical treatment has enabled them to support junior medical staff, and to promote the continuity of appropriate care. They are more active in the education of patients, relatives and staff, and have identified specific developments which will be informed by the knowledge they have gained. It also proved beneficial to junior medical staff with whom interdisciplinary working has improved. Each organization involved in facilitating the initiative also benefited by gaining mutual understanding and appreciation of systems, constraints and opportunities. Equally, relationships among them have been strengthened and key issues with practical solutions have been identified to inform future joint ventures. Indications suggest that there would be value in using this case study to inform a structured pilot project involving other modules of learning and potentially other disciplines. If successful it could benefit all health-care professionals, particularly those senior staff who are expanding their roles and have educational needs unmet by existing provision. In addition to providing complementary opportunities this format provides a mechanism to enhance the mutual understanding essential to effective teamwork.

Education, Medical, Undergraduate↗
PubMed1999

Primary care physicians should be coordinators, not gatekeepers.

Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre-managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both over-referral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.

Case Management↗
PubMed1996

Molecular fragile X screening in normal populations.

In December, 1993, we initiated a pilot project in which DNA fragile X (fraX) testing was offered during routine prenatal or genetic counseling to all pregnant women seen at the Genetics & IVF Institute, most of whom were referred for the indication of advanced maternal age. A brochure on fragile X syndrome was sent to each patient prior to her appointment and was reviewed by a counselor or physician during the counseling session. As of June 1995, 3,345 patients were offered testing; 474 women with no identified family history of mental retardation or learning disability and 214 women with a positive family history accepted the test on a self-pay basis. The second population screened was 271 potential donors in our anonymous egg donor program. DNA from blood was tested by Southern blot using EcoRI/EagI and StB12.3. If an expansion was detected, CGG repeat number was determined by PCR-based analysis. Among the 474 patients with unremarkable family histories, three fraX carriers were identified (repeat sizes = 60+), whereas none were found in the 214 patients with a positive family history. Among the potential egg donors, two high borderline patients were identified (repeat sizes = between 50 and 59). Our ongoing study indicates that screening of pregnant or preconceptual populations for fraX carrier status using DNA testing is accepted by many patients and is an important addition to current medical practice.

Chorionic Villi Sampling↗
PubMed1996

PetCR46, a gene which is essential for respiration and integrity of the mitochondrial genome.

In the frame of the European Pilot Project for the functional analysis of newly discovered open reading frames (ORFs) from Saccharomyces cerevisiae chromosome III, we have deleted entirely the YCR46C ORF by a one-step polymerase chain reaction method and replaced it by the HIS3 marker in the strain W303. The deletion has been checked by meiotic segregation and Southern blot analyses. Characterization of the deleted strain indicates that YCR46C is essential for respiration and maintenance of the mitochondrial genome since its deletion leads to the appearance of 100% of cytoplasmic petites. Hybridization with molecular probes from mtDNA of individual clones of such petites showed that about 50% did hybridize (rho- clones) while others did not (possibly rho degrees clones). The wild-type gene has been cloned and shown to complement the deletion. The gene, which probably codes for a mitochondrial ribosomal protein, has been called petCR46.

Base Sequence↗
PubMed1997

Construction of a yeast strain deleted for the TRP1 promoter and coding region that enhances the efficiency of the polymerase chain reaction-disruption method.

The sequence of the genome of Saccharomyces cerevisiae was recently determined. As well as all the informations concerning the structure of the chromosomes the scientific community had to deal with the discovery of dozens of new open reading frames (ORFs) of unknown function. The study of these ORFs requires the development of simple procedures that can be used on a large scale. In the framework of a European Pilot Project we have described a new approach for deleting ORFs. This method is based on transformation with a polymerase chain reaction product but is limited by the use of a strain deleted for the auxotropic marker. We present here the construction of a new recipient strain that lacks the TRP1 region and that allows a high efficiency of gene deletion.

Aldose-Ketose Isomerases↗
PubMed1999

Chemotyping of yeast mutants using robotics.

By now, the EUROFAN programme for the functional analysis of genes from the yeast genome has attained its cruising speed. Indeed, several hundreds of yeast mutants with no phenotype as tested by growth on standard media and no significant sequence similarity to proteins of known function are available through the efforts of various laboratories. Based on the methodology initiated during the pilot project on yeast chromosome III (Yeast 13, 1547-1562, 1997) we adapted it to High Throughput Screening (HTS), using robotics. The first 100 different gene deletions from EUROSCARF, constructed in an FY1679 strain background, were run against a collection of about 300 inhibitors. Many of these inhibitors have not been reported until now to interfere in vivo with growth of Saccharomyces cerevisiae. In the present paper we provide a list of novel growth conditions and a compilation of 49 yeast deletants (from chromosomes II, IV, VII, X, XIV, XV) corresponding to 58% of the analysed genes, with at least one clear and stringent phenotype. The majority of these deletants are sensitive to one or two compounds (monotropic phenotype) while a distinct subclass of deletants displays a hyper-pleiotropic phenotype with sensitivities to a dozen or more compounds. Therefore, chemotyping of unknown genes with a large spectrum of drugs opens new vistas for a more in-depth functional analysis and a more precise definition of molecular targets.

Antifungal Agents↗
PubMed1997

Medical oncology and geriatric medicine: is it time for fellowship integration?

Although training programs exist in both medical oncology and geriatrics (approved by the American Board of Internal Medicine), neither is adequate to ensure an appropriate supply of physicians to assume a leadership role in the treatment of the increasing number of geriatric patients who have or will develop a malignancy. A proposal for offering a 3-4 year program leading to dual certification is under consideration. A careful review of both the medical oncology training program and added qualifications in geriatrics has identified key components of each that can serve as a basis for a combined program. Such a program can encourage research into behavior modification of existing biases in referring geriatric oncology patients for treatment as well as a better understanding of the biology of aging, addressing in particular the pharmacology of anticancer agents in this unique population. It is anticipated that pilot projects will be undertaken to develop common pathways for developing combined programs in medical oncology and geriatrics. The second phase will include recruitment of selected candidates who are interested in an academic career in geriatric oncology. A need for additional academic-based geriatric oncologists has been identified that can address the anticipated increase in the incidence and presence of cancer in an aging population. Such a cadre of specialists will be in an excellent position to recommend changes in the current (mostly negative) approach to the management of cancer in patients age > 65 years.

Aged↗
PubMed1998

Genetic monitoring of malathion-exposed agricultural workers.

The aerial application of malathion over large urban populations in Southern California during the early 1990s raised concerns about adverse health effects, including the potential to cause genetic damage. Workers in the Mediterranean fruit fly eradication program, which involved application of malathion as ground treatment, were studied to examine micronucleus formation and mutation frequencies assessed by the glycophorin A (GPA) assay. In the 1992 pilot project the mean micronuclei level appeared higher in lymphocytes of exposed workers (n = 13) compared to controls (n = 4) (20.1 +/- 7.1 vs 14.3 +/- 7.2 respectively, P = 0.09). During the 1993 season, neither of the cohorts examined showed a higher level of micronuclei in workers exposed to malathion compared to unexposed, nor did the pooled total (n = 53; means = 17.8 +/- 7.2 vs 18.5 +/- 6.3, respectively), even after adjustment by multiple regression. The GPA variant frequency was not associated with malathion exposure in any of the cohorts. These results suggest that any potential risk of genotoxic damage from exposure to malathion is relatively low, but other assays may be more sensitive, and the sample size was small.

Adult↗
PubMed1998

Mental health costs and outcomes under alternative capitation systems in Colorado: early results.

BACKGROUND: This study presents preliminary findings for the first nine months of the State of Colorado USA Medicaid capitation Pilot Project. Two different models of capitation (model I and model II) are compared with fee for service (FFS) in providing services to severely and persistently mentally ill adults. In model I the state's mental health authority contracts with community mental health centers (CMHCs) who both manage the care and deliver mental health services, while in model II the state contracted with a joint venture between a for-profit managed care firm who manage the care with either a single CMHC or an alliance of CMHCs who deliver the mental health services. AIMS: Our objective is to examine utilization, cost and outcomes of inpatient and outpatient (including community based) services before and after the implementation of a capitated payment system for Colorado's Medicaid mental health services compared to services that remained under FFS reimbursement. METHODS: The stratified, random sample includes 513 consumers (188 for model I, 179 for model II, and 146 for FFS). Consumer outcomes were collected by trained interviewers and include 17 measures of symptoms, health status, functioning, quality of life and consumer satisfaction. Utilization and cost of services are from the Medicaid claims data and a shadow billing data system (post-capitation) designed by Colorado. The first step of the two-step regression procedure adjusts for the presence of individuals with use or no service use during the specified time while the second step, ordinary least-squares regression, is applied to the sample who utilized services. RESULTS: These preliminary findings indicate consistent reductions in inpatient user costs and probability of outpatient use under capitation. Combining all services, there are consistent reductions in the probability of use in both models: model I had significantly higher initial probability of use for any service. Only model II showed a statistically significant decrease in post-capitation overall user costs, but they were initially higher than model I or FFS. Estimated total cost per person for model I suggests virtually no change from the pre- to post-capitation period. Model II had the highest pre-capitation and the lowest post-capitation estimated cost per person. Examination of pre measures of outcomes across capitated areas suggest that samples drawn from the FFS, model I and model II areas were comparable in severity of psychiatric symptoms, functioning, health status and quality of life. No changes were found in outcomes. DISCUSSION: These early findings are consistent with the limited literature on capitation. Both studies of capitation integrated with medical care and those specific to mental health settings did not find adverse changes in outcomes compared to FFS. Limitations include the short follow-up period, lack of detail and possible under-reporting of outpatient services provided by the shadow billing data system. CONCLUSIONS: For the short term, it is concluded that capitation can reduce service cost per person without significant change in clinical status. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Implications are unclear until we can determine whether (i) reductions in the numbers receiving service indicates favorable consumer outcomes or reductions in access and (ii) lack of change in consumer outcomes is due to the benefits of capitation or the lack of sensitivity of the outcome measures. IMPLICATIONS FOR HEALTH CARE POLICY FORMULATION: Implications are premature for these early findings. IMPLICATIONS FOR FUTURE RESEARCH: Future research should include longer follow-up as well as analysis of long-term consequences for both cost savings and clinical outcomes.

Journal Article↗
PubMedDate not supplied

Genotypes and phenotypes.

Within the framework of a pilot project on the analysis of the mouse proteome, we investigated C57BL/6 mice (Mus musculus), a standard inbred strain of the mouse, starting with the analysis of brain, liver and heart proteins. Tissue extraction and the separation of proteins were performed with techniques offering a maximum of resolution. Proteins separated were analyzed by mass spectrometry. Gene-protein identification was performed by genetic analyses using the European Collaborative Interspecific Backcross (EUCIB), established from the two mouse species Mus musculus and Mus spretus. On the basis of protein polymorphisms we mapped hundreds of genes on the mouse chromosomes, allowing us new insight into the relationship between genotype and phenotype of proteins. In particular, the results showed that protein modifications can be genetically determined, therefore representing their own class of protein phenotypes. In this context, results are discussed suggesting that phenotypes of single protein species may result from several genes. Accordingly, proteins are considered as polygenic traits. In contrast, one example demonstrates that proteins may also have pleiotropic effects: a single gene mutation (a single altered protein) may affect several other proteins. From these studies we conclude that gene-related functional proteomics will show in the future that genetic diseases, defined today by clinical symptoms and considered as etiological entireties, can be subdivided into different diseases according to different affected genes.

Animals↗
PubMed1990

Farmers' health and safety programs in Sweden.

In 1977, the Swedish Farmers' Federation initiated a pilot project of preventive occupational health services to farmers. After a few years it was decided that this occupation-specific service, Farmers' Preventive Health Service (Lantbrukshälsan), should be permanently established within the federation of farmers. Today, 33 special regional centers have been established around Sweden, providing occupational health services to farmers, farm workers, and others occupied in farm-related enterprises. At another 30 locations collaboration has been established with other existing health care centers. Farmers must pay a fee to become a member of the organization and to provide affiliation is voluntary. Today about 40,000 farmers are members. The main goal of the farmers' preventive health service (FPHS) is to prevent work-related injuries and illnesses and to provide clinical services to farmers for occupational medical problems. Every second year a health check-up is performed; during the years in between other services such as farm visits, first aid courses, and sessions on prevention/amelioration of back and neck problems are provided. A team of occupational nurses, physiotherapists, agricultural safety engineers, doctors, and secretaries work together to provide comprehensive services. This integrated medical-technical approach to service provision is a prerequisite to successful intervention for the many occupational hazards which may cause damage to health. Respiratory problems related to inhalation of organic dust, pesticide exposures, allergies, and orthopedic diseases are important. Psychosocial work-related problems seem to be increasing among farmers.

Accidents, Occupational↗
PubMed2006

Genetic disorders among Palestinian Arabs. 4: Genetic clinics in the community.

Genetic disorders are frequent in the Arab population of Israel, mainly because of the preference for consanguineous marriages. Many of the inherited diseases are present with a high frequency only in a limited region or a single village. It is therefore not surprising that, in each of the villages, a different distribution of genetic diseases is found; thus, a detailed knowledge of the genetic disorders present in each village is of utmost importance for genetic counseling. As a direct consequence of these observations two community genetics clinics were opened as a pilot project to study their impact on the population to be served. The use of a computer database allowed for easier and more accurate genetic counseling. There were almost 1,500 visits in the 4-year period since the introduction of the services. During the years an increase in the mean number of consultations per clinic as well as a change in the type of referrals was observed. There was an increasing proportion of clinics that were made at a time in which genetic counseling allow for primary prevention. The presence of a genetic counselor in the village clinic allows for better and closer contacts with the family physician.

Arabs↗
PubMed2002

Effectiveness of human microsatellite loci for assessing paternity in a captive colony of vervets (Chlorocebus aethiops sabaeus).

Microsatellite polymorphisms are playing an increasingly vital role in primatological research, and are particularly useful for paternity exclusion in both wild and captive populations. Although vervet monkeys (Chlorocebus aethiops) are commonly studied in both settings, few previous studies have utilized microsatellite markers for assessing genetic variation in this species. In a pilot project to assess paternity in the UCLA-VA Vervet Monkey Research Colony (VMRC), we screened 55 commercially available human microsatellite markers chosen from a panel of 370 that have been shown to be polymorphic in baboons (Papio hamadryas). Using a standard PCR protocol, 43 (78%) loci produced amplifiable product. Of these, 14 were polymorphic and 11 were genotyped in 51 individuals, including 19 offspring and 14 potential sires. The average heterozygosity across the 11 loci was.719. In all 19 paternity cases all but one male was excluded as the true sire at two or more loci. This includes successfully distinguishing between two maternal half-sib brothers who were potential sires in most of the paternity cases. Given that the colony is descended from 54 wild-caught founders trapped between 1975 and 1987 from an introduced population on St. Kitts, West Indies, these values imply high microsatellite variability in natural vervet populations. Our results provide a panel of markers derived from the human genome that is suitable for assessing genetic variation and paternity in vervets.

Animals↗
PubMed2004

Laser scanning cytometry for the detection of neoplasia in urologic cytology specimens.

BACKGROUND: The objective of the current pilot project was to assess the efficacy of laser scanning cytometry (LSC) for DNA ploidy analysis of atypical urologic cytology specimens to enhance the distinction between benign and malignant changes. METHODS: Forty selected urologic cytology specimens that previously had been categorized as normal, atypical, or malignant were studied. Nuclear propidium iodide and fluorescence intensity measurements were converted to pixel values, which were used to create scattergrams that excluded debris and cell clusters from ploidy analysis, creating a gated (isolated) region of predominantly single cells for LSC ploidy analysis. Integral histograms then were created to show the number of cells present in diploid, tetraploid, and aneuploid peaks; these histograms also were used to assess DNA ploidy. RESULTS: Ten normal specimens, 10 malignant specimens, and 20 atypical specimens were examined to assess the efficacy of LSC ploidy analysis. Normal and malignant specimens generated reference histograms for comparison with the atypical specimens and exhibited 90% specificity and 100% sensitivity. Ten atypical aneuploid specimens had histogram and scattergram patterns similar to those produced by malignant specimens and, using the cytometer's relocation feature, the presence of atypical cells was confirmed in the aneuploid regions. CONCLUSIONS: The authors determined that DNA ploidy analysis of atypical urologic cytology specimens using LSC is a useful adjunct tool for identifying malignant specimens that lack sufficient cytologic criteria for diagnosis by light microscopy alone. However, LSC is time consuming and requires expensive equipment.

Aneuploidy↗