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PubMed2004

Role of mitochondria in HIV lipoatrophy: insight into pathogenesis and potential therapies.

Lipoatrophy is a selective loss of subcutaneous adipose tissue and a highly prevalent complication of antiretroviral therapy (ART). This form of fat wasting is associated with decreased quality of life, disincentive for adherence to antiretroviral therapy, as well as possibly an increased risk of coronary artery disease. Clinical trials have incriminated long-term ART with nucleoside analogue reverse transcriptase inhibitors (NRTIs) in general and stavudine in particular. The exact mechanism of fat wasting remains unclear, but the pathogenesis can largely be attributed to the mitochondrial toxicity of NRTIs. NRTIs are inhibitors of polymerase gamma, an enzyme which is necessary for the replication of mitochondrial DNA (mtDNA). Indeed, low amounts of mtDNA, abnormalities of mitochondrial ultrastructure, and respiratory chain dysfunction were identified in the subcutaneous fat tissue and skeletal muscle of HIV-patients under ART and linked to the use of stavudine. Switching away from the incriminated NRTI, is of proven benefit, but may not always be feasible. Supplementation with uridine should be investigated in the prevention and treatment of lipoatrophy based on its potential to competitively attenuate the mtDNA decline caused by pyrimidine NRTIs.

Journal Article↗
PubMed2003

Stigma as a barrier to treatment of sexually transmitted infection in the American deep south: issues of race, gender and poverty.

Sexually transmitted infections (STI) occur at high rates in the US compared to other Western nations. Sociocultural indicators such as race and ethnicity, lower socioeconomic status and historically higher rates of certain diseases, such as syphilis, are correlated factors but do not explain fully why STI rates are particularly high in the American Deep South. One salient factor is the stigma associated with STI and its effect on screening and treatment. This paper presents the results of six focus group interviews that were conducted among mainly African-American health workers, patients and students in Alabama, USA. The results showed that STI-related stigma directly and indirectly affected willingness to be treated for STI at public health clinics. Four dimensions of stigma emerged: (1) Religious ideation affected how health workers felt about 'promiscuous' patients (especially women), (2) privacy fears discouraged male patients from seeking treatment at local clinics, (3) racial attitudes affected willingness to be treated for STI and (4) Stigma transference (being "scarlet lettered") emerged as a potent disincentive to treatment. Partner notification was more likely if patients felt betrayed by a sexual partner. Further research is needed to clarify these stigma-related dimensions and the impact on screening, treatment and partner services.

Adolescent↗
PubMed2006

Patent pools and diagnostic testing.

There is increasing concern that overlapping patents in the field of genetics will create a costly and legally complex situation known as a patent thicket, which, along with the associated issues of accumulating royalty payments, can act as a disincentive for innovation. One potential means of preventing this is for the patent holders to enter into a so-called patent pool, such as those established in the electronics and telecommunications industries. Precedents for these also exist in the field of genetics, notably with the patents pertaining to the SARS genome. In this review, we initially address the patent pool concept in general and its application in genetics. Following this, we will explore patent pools in the diagnostic field in more detail, and examine some existing and novel examples of patent pools in genetics.

Animals↗
PubMed2004

Do we need living unrelated organ donation in Brazil?

The remarkable success achieved by organ transplantation has also engendered the major problem of organ shortage. As a consequence, the use of living unrelated donors (LURD) has been proposed as an ethically justifiable alternative for developed nations to minimize their waiting lists for organ transplantation (OTx). This change in attitude has caused an ethical dilemma for developing countries like Brazil, which is struggling to increase the cadaver donor pool. Due to a huge socioeconomic gap of values and needs among nations, the incentive to use LURD in developed countries may not only produce a disincentive to cadaver organ donation but also stimulate organ trade in developing countries. In this paper we aimed to show that in Brazil, we do not need to use LURD because we have not optimized our cadaver donor pool. The exploitation of LURD might be a good option for developed countries, but it is not useful for developing countries. The Transplantation Society urgently needs to solve and clarify this problem by establishing basic ethical and justice principles that can serve as a guide for every country, throughout the entire process required, to achieve an adequate pool of cadaver donors.

Bioethics↗
PubMed2004

Laparoscopic donor nephrectomy: new combination of hand-assisted and standard approaches.

BACKGROUND: Although laparoscopic live donor nephrectomy (LLDN) was conceived to decrease morbidity and reduce donor disincentives, it requires considerable experience. We present a new combination of hand-assisted and standard laparoscopic approaches to live donor nephrectomy. METHODS: Between March 2002 and February 2003, ten LLDNs were performed with the new procedures. Using the new methodology the surgeon can withdraw his hand and insert a trocar through the hand-assisted device whenever he desires. Although the hand-assisted procedure was performed in most patients, we attempted to dissect the renal hilum without hand assistance in the final patient, successfully procuring the kidney. RESULTS: Mean operation time was 245 minutes and warm ischemic time was 179 seconds. No vascular, renal parenchymal, or ureteral injuries occurred. The patient with multiple left renal arteries had a longer warm ischemic time and delayed graft function. Mean predonation creatinine was 0.97 mg/dL, it increased to 1.44 and 1.15 mg/dL at 7 days and 3 months postdonation, respectively. One patient had chylous ascites and another had a transient left brachial plexus paralysis. CONCLUSIONS: Both pure laparoscopic and hand-assisted LLDN have advantages and disadvantages. In our modification, the free conversion from hand-assisted to a purely laparoscopic approach allows the surgeon to practice two procedures simultaneously. With this combination, 90% of the LLDN were accomplished, with pure laparoscopy in the last case.

Humans↗
PubMed2005

A consecutive series of 70 laparoscopic donor nephrectomies demonstrates the safety of this new operation.

Laparoscopic donor nephrectomy (LDN) has the potential to overcome some of the disincentives to living kidney donation. This study presents the results of a consecutive series of 70 LDN from a single center with an emphasis on postoperative complication rates and donor recovery times. There was no selection bias based on donor body mass index or because of difficult vascular anatomy. All donors received postoperative analgesia using a patient-controlled system and returned to activities and employment at their discretion. There was no donor mortality and no episode of thromboembolic disease. One operation was converted from open to LDN because of renal artery bleeding. Postoperative complications encompassed chest infection (6%), unilateral pulmonary edema (3%), ileus (3%), wound infection (3%), paraesthesia of L1 (4%), testicular pain (3%), persistent wound pain (1.4%), and reoperation for division of adhesions (3%). In conclusion, LDN is a safe procedure with low postoperative morbidity. There were some unexpected complications, but recovery time was short.

Female↗
PubMed2002

Inherent flaws in a method of estimating meal intake commonly used in long-term-care facilities.

OBJECTIVE: To evaluate the accuracy of a method used to estimate nursing home residents' meal consumption, where the meal tray is assessed as a whole and assigned a value of 0%, 25%, 50%, 75%, or 100% consumed, under both routine and controlled conditions. SUBJECTS/SETTING: This study was conducted with certified nursing assistants at a 180-bed long-term-care facility in Miami, Fla. METHODS: Study 1 evaluated the method under routine conditions by comparing nursing assistants' estimates to actual meal consumption of 42 residents over 109 meals. A second study evaluated the method in a controlled setting where nursing assistants were free of disincentives and distractions that might contribute to inaccurate reporting. In a crossover design, nursing assistants estimated consumption on 4 manipulated trays under conditions of both immediate and delayed reporting. STATISTICAL ANALYSIS: An intraclass correlation coefficient and percent agreement were used to compare nursing assistants' estimates to weighed meal intakes. RESULTS: Under routine conditions, the intraclass correlation coefficient between nursing assistants' estimates and the actual resident meal consumption was weak at 0.464 (95% confidence interval=0.146 to 0.664). The correct estimate was recorded 44% of the time. In the controlled setting, the nursing assistants' estimates for percent consumed agreed with weighed intakes 44% and 38% of the time with immediate and delayed recording, respectively. APPLICATIONS/CONCLUSIONS: This 1-step method of estimating meal consumption with an overall percentage is not sufficiently accurate to identify residents who are eating less than 75% of most meals.

Aged↗
PubMed1997

Industrial rehabilitation medicine. 1. Why is industrial rehabilitation medicine unique?

This self-directed learning module is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Industrial rehabilitation medicine encompasses injuries and illnesses that occur in the workplace and are covered under workers' compensation. The central thesis of this article is that industrial rehabilitation medicine is a unique area because the workers' compensation system influences the behavior of injured workers. The article is divided into three sections. The first briefly reviews the history of workers' compensation in the United States, and describes eight key features of compensation systems. The second explores several hypotheses to explain why injured workers frequently have less favorable outcomes than noncompensation patients with similar medical conditions. Some explanations focus on dysfunctional psychologic reactions such as "compensation neurosis" and "disability syndrome." Others focus on contextual factors, including return to work policies by employers and financial incentives or disincentives for return to work. The third section outlines reasons why the physiatrist is often the "preferred provider" in industrial rehabilitation medicine. One crucial consideration is that many of the most important disabling work injuries are those with which physiatrists are familiar. Also, physiatric training and philosophy prepare the physician to focus on function, to work with a rehabilitation team, and to be sensitive to psychologic factors that might impede an injured worker's recovery. All of these skills are important in the treatment of injured workers.

Chronic Disease↗
PubMed2002

Orthodontic referrals via TeleDent Southwest.

The information presented in this article must be interpreted with caution. Ideally the trial should have lasted longer because five of the seven participating dentists said they felt constrained from taking in more cases because access to TeleDent advice would cease before completion of all but the shortest of treatments. Second, the number of practitioners recruited into the trial was small, and the dentists chosen were highly selected. Third, almost all the data are based on the opinions of the participating dentists, and for three of the dentists the number of cases on which those opinions were based was small. Finally, it must be remembered that all United Kingdom NHS dentists are busy and work on a highly structured "time of service" payment system. Although the costs of hardware, software, line rental, and training were borne by the TeleDent project, there was no financial compensation for the time spent by dentists capturing images of their patient records and putting together the whiteboard and transmitting the information. There was a significant financial disincentive for using the system. Ideally, a long-term prospective randomized study of the effect of teledentistry advice on outcome of orthodontic treatment provided by general dental practitioners should be undertaken. The data collected in the current study supported the dentists' opinions that TeleDent SW enabled them to offer a better service for their patients and use specialist services more appropriately.

Computer Communication Networks↗
PubMed1997

Physiology, pharmacology and parasitology.

The developing resistance to current chemical classes of broad-spectrum anthelmintics and insecticides presents an undeniable threat to the long-term viability of the animal health industry. Alternative treatment strategies including vaccines, biological control and breeding of parasite-resistant animals are unlikely to be widely available in the near future and even then they will be integrated with chemotherapy. The significant cost of research and development of new therapeutics for food-producing animals, together with the small market share of animal health products, particularly in Australia and New Zealand, is a positive disincentive for drug development. The chemical actives that are currently available are all that we are likely to have for the foreseeable future and they must be used more efficiently. Understanding the pharmacokinetic behaviour of antiparasitics and recognising the potential for the animal's physiological characteristics to assist drug action is crucial. Careful administration, coupled with a reduction of feed intake before oral anthelmintic treatment, maximises drug availability and therefore increases efficacy of the benzimidazole and ivermectin compounds. This is a cost-effective option that can be employed immediately, which not only increases efficacy of "older" compounds but will be instrumental in prolonging the useful life of the newer drugs. Taking care to apply topical insecticide formulations directly along the backline immediately after shearing will maximise even diffusion of active around the sheep flanks to contact lice inhabiting sites remote from the point of drug application. The use of "intelligent" formulation and delivery of existing compounds, based on knowledge of host physiological and pharmacological responses, holds the key to effective antiparasitic treatment.

Animals↗
PubMed1988

Access and quality of care for urology patients under diagnostic related group reimbursement.

The Diagnostic Related Group payment mechanism is rapidly changing economic incentives for hospitals. We studied resource consumption and age for a large group of urology patients under Diagnostic Related Group reimbursement. Total hospital costs (exclusive of Diagnostic Related Group reimbursement. Total hospital costs (exclusive of physician fees) for the 1,281 urology patients studied were $8,895,264. Older urological patients consumed a disproportionately larger share of hospital resources. Mean hospital cost per patient, mean number of procedures, hospital length of stay and mortality generally increased with age. Under Diagnostic Related Group reimbursement, financial risk increased with age; patients 75 years and older generated significant financial risk to the hospital. Older patients often had a more intense resource use as measured by emergency or surgical intensive care unit admission, and blood and plasma protein requirements. These findings suggest that the current Diagnostic Related Group payment scheme may provide significant financial disincentives to hospitals vis-à-vis older urology patients and, thus, it could limit the access and quality of care for the older urology patient in the future.

Adult↗
PubMed1999

A dynamic model of drug initiation: implications for treatment and drug control.

We set up a time-continuous version of the first-order difference equation model of cocaine use introduced by Everingham and Rydell [S.S. Everingham, C.P. Rydell, Modeling the Demand for Cocaine, MR-332-ONDCP/A/DPRC, RAND, Santa Monica, CA, 1994] and extend it by making initiation an endogenous function of prevalence. This function reflects both the epidemic spread of drug use as users 'infect' non-users and Musto's [D.F. Musto, The American Disease: Origins of Narcotic Control, Oxford University, New York, 1987] hypothesis that drug epidemics die out when a new generation is deterred from initiating drug use by observing the ill effects manifest among heavy users. Analyzing the model's dynamics suggests that drug prevention can temper drug prevalence and consumption, but that drug treatment's effectiveness depends critically on the stage in the epidemic in which it is employed. Reducing the number of heavy users in the early stages of an epidemic can be counter-productive if it masks the risks of drug use and, thereby, removes a disincentive to initiation. This strong dependence of an intervention's effectiveness on the state of the dynamic system illustrates the pitfalls of applying a static control policy in a dynamic context.

Cocaine-Related Disorders↗
PubMedDate not supplied

The cost-effectiveness of transplantation with expanded donor kidneys.

Transplantation with EDKs is a cost-effective therapy for ESRD as compared to hemodialysis across a variety of clinical and financial scenarios. In many cases the costs of pursuing transplantation with these donors will exceed hospital reimbursement for the procedure, providing a financial disincentive to pursuing a clearly cost-effective therapy.

Cadaver↗
PubMed1987

Prudent laboratory usage, cost containment, and high quality medical care: are they compatible?

Inappropriate laboratory use by physicians is partly responsible for the rapid rise in health care costs. This use falls into three categories--over-, under-, and misutilization. Overuse creates information overload for the physician and has a detrimental effect on patient care. Abnormal results are frequently obscured by massive amounts of requested information. Studies show that laboratory use is greater for younger physicians and that increased use is not associated with better outcome of care. Overuse ranges from 26 per cent to 98 per cent for selected tests. Unnecessary tests can be eliminated with no adverse effect on quality. Laboratory use can be improved by a variety of approaches including education, feedback, implementation of administrative changes and, finally, financial incentives or disincentives; the last has proven the most effective. All the approaches should be reinforced by cost-conscious clinical settings that foster a "why" rather than a "why not" philosophy. Improving laboratory use may reduce costs and maintain quality.

Cost Control↗
PubMed2002

Chylous ascites secondary to laparoscopic donor nephrectomy.

Live donor renal transplantation offers many significant advantages over cadaveric donor transplantation. Yet living donation continues to be underused, accounting for less than 30% of all donor renal transplants. In an attempt to remove the disincentives to live donation, Ratner et al. developed laparoscopic donor nephrectomy (LDN). LDN is gaining acceptance in the transplant community. The overriding concern must always be the safety and welfare of the donor. To this end, potential complications of LDN must be identified and discussed. We present a patient who developed the complication of chylous ascites from LDN. To improve the laparoscopic technique further, a discussion of its successes and complications needs to be encouraged. To this end, we present chylous ascites as a potential complication after LDN. We also offer suggestions to minimize the likelihood of this complication.

Adult↗
PubMed2003

Evidence-based follow-up of lung cancer patients.

Evidence-based follow-up care of the lung cancer patient is straightforward with periodic histories and physical examinations recommended to detect recurrence. Yearly chest radiographs to detect second primaries "may be reasonable" in small and non-small cell lung cancer patients. The routine use of computed axial tomography (CAT) scans, bone scans, brain imaging, and serum tumor markers is not recommended in lung cancer patients. Many patients receive more extensive and expensive follow-up after treatment, despite the lack of curative options for recurrent lung cancer or evidence that earlier treatment of recurrence leads to better medical outcomes. The reasons for this are not known at present but could involve patient or physician preference, with no disincentives for extra testing. Adherence to breast cancer follow-up clinical practice guidelines at one cancer center reduced cost by one third with no change in health outcomes, but no studies have been performed in lung cancer.

Carcinoma, Non-Small-Cell Lung↗
PubMed2001

Laparoscopic live donor nephrectomy. A review of the first 5 years.

Laparoscopic live donor nephrectomy is technically feasible. The operation has evolved over the last 5 years and is greatly improved compared with the procedure originally described. Advantages to the donor when compared with the standard open operation are decreased postoperative pain, shorter hospitalization, a quicker recuperation, an earlier return to driving, and an earlier return to employment. These improvements have resulted in fewer lost wages and a lower financial burden for donors. Live donor nephrectomy also provides improved cosmetic results. It successfully removes many of the disincentives to live kidney donation and has resulted in an increased willingness of individuals to donate their kidneys. The operative risk seems to be equivalent to that of the open donor operation performed through a flank approach. Although there is no financial advantage of the laparoscopic operation in terms of hospital costs, the increase seen in live donor transplantation may result in long-term cost savings overall. Kidneys procured laparoscopically function well in recipents in the short and long term. There is no increased risk for rejection or technical complications, and the recipent's length of hospitalization is unaffected. The laparoscopic donor operation does not have any apparent deleterious effect on the recipient. The procedure is being adopted rapidly by transplant centers around the world and has been performed at more than 100 centers on five continents. The authors believe that laparoscopic live donor nephrectomy will become the standard of care in the not too distant future.

Humans↗
PubMed1999

Laparoscopic live donor nephrectomy.

Live donor renal transplantation has many advantages including greater graft and patient survival, shorter waiting periods, improved human leukocyte antigen matching, and less cold ischemia. Until recently, disincentives from the operation, such as prolonged hospitalization, postoperative pain, and significant convalescence, have deterred live donor renal transplantation. This article describes the technique of laparoscopic live donor nephrectomy and briefly reports the results. The procedure has resulted in improved postoperative recovery and shorter convalescence, with no effect on recipient renal function.

Humans↗