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Inhibition of experimental allergic encephalomyelitis in the Lewis rat by paclitaxel.

Experimental allergic encephalomyelitis (EAE), an animal model for multiple sclerosis (MS), is useful for preclinical testing for agents to be considered for treatment for this human demyelinating disease. Microtubules in lymphocytes play an important role in the cascade of human T cell activation, and paclitaxel (PTX), a microtubule stabilizer, can inhibit T cell function. A new formulation of micellar PTX, free of Cremophor and ethanol, was tested for its effect on the induction of EAE in Lewis rats. Adoptive EAE was induced with an encephalitogenic T cell line activated with guinea pig myelin basic protein (GP MBP) peptide 68-88. PTX (10 mg/kg) was administered 24 and 72 h after cell transfer. The clinical signs, fulminating in controls, were completely blocked by PTX, but mild CNS inflammation remained unaltered. A similar dose of PTX, given on days 6 and 8 to animals developing active EAE after immunization with GP MBP peptide 68-88 in complete Freund's adjuvant, greatly reduced the severity of paralysis and delayed the onset of disease by 8-9 days. Marked weight loss and severe toxicity were noted with higher and more prolonged administration. In vitro micellar PTX inhibited activation of encephalitogenic T cells by both specific antigen and mitogen. Lower doses and longer treatment programs may provide effective treatment with acceptable adverse effects with this agent in the treatment of inflammatory demyelinating disease.

Amino Acid Sequence↗

The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community.

A cross-sectional study was conducted to investigate the influence of the co-payment policy in a community setting on the purchase of prescription medications for children with acute infections. Data for all purchased medications prescribed for children with an acute infectious disease were gathered from a pediatric health care center over a 6-week period. Parents of the sick children and controls were interviewed by telephone, using a short sociodemographic questionnaire, and were asked to state their reasons for not purchasing (either partially or completely) necessary medications, primarily antibiotics. Of the 779 children who received a prescription for antibiotics during the 6-week period, 162 (20.7%) failed to take the complete course of antibiotic treatment. One hundred and one parents of these children (62.3%) were interviewed, of whom 30 (29.7%) claimed that the main reason for not buying the full course of antibiotic medication was the cost. This group is characterized by low income, overcrowded housing conditions and a large quantity of prescription medications. The cost of prescribed medication under the co-payment policy is a serious barrier to the purchase of prescribed medication for children with acute infections in the primary care setting. The policy has a particularly deleterious effect in under-privileged populations and is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Israeli Health Insurance Law and similar laws in other western countries.

Acute Disease↗

[Tuberculosis among immigrants in Bilbao (Spain)].

OBJECTIVE: To assess the prevalence of tuberculosis (TB) and latent tuberculous infection among immigrant residents of Bilbao who came from countries where the disease is highly prevalent. We also studied related social and health conditions. MATERIAL AND METHODS: A descriptive study carried out in the San Francisco neighborhood of Bilbao. Subjects were enrolled during a seven-month period by a social worker and by the personnel of a non-governmental organization (Médicos del Mundo) who recruited volunteers from among persons requesting medical or social assistance. The subjects who agreed to participate answered systematic questionnaires on social and medical conditions and were given tuberculin tests and chest X-rays. RESULTS: We initially evaluated 406 immigrants (mean age 32.5 years; SD 9.7) mainly from sub-Saharan Africa, 83.2% of whom were undocumented. Three hundred six completed the study (75.4%). Compliance was higher among those who applied for medical certificates (p = 0.039) or who were symptomatic (p = 0.016). Thirty-one subjects had been exposed and 0.83% had active TB. CONCLUSION: We believe that TB screening tests for recently arrived immigrants are necessary given the high rate of exposure and disease. Incentives and the cooperation of non-governmental organizations could improve acceptance of and compliance with such programs.

Adolescent↗

Sources of information about cancer as perceived by adolescent patients, parents, and physicians.

As survival time has been extended for young cancer patients, their informational needs have also increased. Using written questionnaires, we surveyed 63 adolescent patients, 60 parents, and 53 physicians to compare their perceptions of patient-communication patterns and current and preferred information sources. Physicians were the main current and preferred information sources noted by all three groups. Group discussions with patients the same age, films and television programs, and books were ranked as acceptable but less preferable sources by more than half of each group. More than 90% of the patients were usually accompanied by a parent. Patients most frequently sought their parents to discuss general concerns and cited parents as their second most frequently used source of disease-related information. Adolescents qualified their parental discussions more than was perceived by their parents (P less than 0.01) and viewed themselves as discussion initiators more frequently than did their parents (P less than 0.05). Parents were more likely than patients to prefer physicians as their child's information source (P less than 0.05). Physicians consistently underestimated their own and the parents' importance, believing instead that the patients relied more on peers. Fewer physicians than patients or parents favored including parents in discussion with health professionals (P less than 0.001).

Adolescent↗

Exercise and the nutritional management of diabetes during pregnancy.

Although exercise is widely accepted as an important component in programs of maintaining a healthy lifestyle, the question of safety and utility of an exercise program for pregnant diabetic women is still controversial. Pregnant women who have diabetes want some direction as to what their possibilities are regarding exercise programs, as there is accumulating evidence that exercise during pregnancy has some advantages for them. In addition, there is now a consensus of thought that the ideal nutritional therapy for the gestational diabetic woman is a diet that facilitates normoglycemia. This article outlines a program that not only improves metabolic control through dietary principles and exercise prescriptions to achieve and maintain normoglycemia, but also will be safe for the mother and her baby, is enjoyable, and also has physical benefits for the mother.

Blood Glucose↗

Utilization of screening mammography--1990.

Although much has been accomplished in the last few years toward the early detection of breast cancer, we are far from a goal of universal acceptance of the recommended preventive health program of screening mammography. To take an analogy from the Papanicolaou smear, we are somewhere in the 1960s. Both women and physicians have more to learn, and they need to transfer that knowledge into practice.

Adult↗

Accreditation: a "voluntary" regulatory requirement.

Hospitals and ambulatory surgery centers may choose to voluntarily apply for accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), or the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) as appropriate. The facilities must comply with written standards regarding the environment of care, the provision of care, and the quality of care. Regular surveys of the organization's performance by the accrediting agency are intended to ensure the quality of care provided to the patients entrusted to our care. The accreditation process certifies to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program. Perianesthesia nurses should have an understanding of the regulatory agencies that influence daily patient care. This article provides an overview of the 3 accrediting bodies: JCAHO, AAAHC, and AAAASF. These agencies are committed to improving safety by providing standards of care, survey evaluations, and professional consultative and educational services, and they have an important role in our health care environments.

Accreditation↗

Consumer turnover in service utilization patterns: implications for capitated payment.

Risk-adjusted capitation rates based on a group's expected cost to a provider have been proposed to create incentives for including people with severe mental disabilities in managed healthcare systems. The most appropriate methods for classifying people according to levels of risk, however, have yet to be determined. This research employed cluster analysis statistical techniques to identify patterns of services delivered to a sample of 4,346 consumers in Ohio. Findings about the extent of client movement in and out of service clusters over time suggest caution in the implementation of risk-adjusted capitation plans, particularly those based primarily on past service utilization.

Capitation Fee↗

The impact of accessibility on the use of specialist health care in Norway.

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.

Decision Making↗

Does using the Internet facilitate the maintenance of weight loss?

OBJECTIVE: The purpose of this study was to investigate the effectiveness of a weight maintenance program conducted over the Internet. DESIGN: Longitudinal, clinical behavioral weight loss trial with 6-month in-person behavioral obesity treatment followed by a 12-month maintenance program conducted both in-person (frequent in-person support; F-IPS, minimal in-person support; M-IPS) and over the Internet (Internet support; IS). SUBJECTS: A total of 122 healthy, overweight adults (age=48.4+/-9.6, BMI=32.2+/-4.5 kg/m(2), 18 male) MEASUREMENTS: Body weight, dietary intake, energy expended in physical activity, attendance, self-monitoring, comfort with technology. RESULTS: Results (n=101) showed that weight loss did not differ by condition during treatment (8.0+/-5 vs 11+/-6.5 vs 9.8+/-5.9 kg, P=0.27 for IS, M-IPS and F-IPS, respectively). The IS condition gained significantly more weight than the F-IPS group during the first 6 months of weight maintenance (+2.2+/-3.8 vs 0+/-4 kg, P<0.05) and sustained a significantly smaller weight loss than both in-person support groups at the 1 y follow-up (-5.7+/-5.9 vs -10.4+/-9.3 vs -10.4+/-6.3 kg, P<0.05 for IS, M-IPS and F-IPS, respectively). Attendance at maintenance meetings was greater for the F-IPS than the IS condition over the 1 y maintenance program (54 vs 39%, P=0.04). Acceptability of assigned condition was higher for subjects in the F-IPS than IS condition. CONCLUSION: The results of this study suggest that Internet support does not appear to be as effective as minimal or frequent intensive in-person therapist support for facilitating the long-term maintenance of weight loss.

Analysis of Variance↗

Impact of technology choice on service provision for universal newborn hearing screening within a busy district hospital.

OBJECTIVE: To investigate the implications of technology choice between automated auditory brainstem response (AABR) and transiently evoked otoacoustic emissions (TEOAE) on service provision for a universal newborn hearing screening (UNHS) program. METHOD: Over a 4-day period, we offered to perform AABR hearing screening on a cohort of 48 well babies in the maternity unit and outpatient department of our busy district hospital. Those parents that consented were asked to sign a consent form and their babies were then screened using the Natus ALGO Model 2e color newborn hearing screener supplied on loan from Neonatal Perspectives Ltd, Manchester, UK. We recorded the patient age at testing, test duration, results obtained (as a pass/refer) and any problems that we experienced with the screening progress, together with parent or user perceived differences between this technology and the current TEOAE screen. A single user carried out all screening. Having collected the AABR data, we then analyzed the implications of the results in relation to service provision in our hospital, utilizing historical data on TEOAE screening. RESULTS: Forty-four mothers, from 48, consented to having their baby screened by AABR and we were able to achieve a result in all 44 babies that we screened. At the standard test criteria of 35 dBnHL, a total 42 babies passed the initial screen in both ears and 2 referred in a single ear only. The test duration was less than 5 minutes for 36 of 44 babies. Applying these results to a model of UNHS generated a per screen cost of 15.98 Pounds for a two-stage OAE/AABR program and 14.25 Pounds for an AABR-only program. Parents found the AABR test acceptable and we found that being able to discuss the screen and hearing with the parents while the screen was taking place both time-efficient and reassuring to parents. In our experience and using our screening model, the OAE/AABR two-stage approach would have generated 509 infants for second-stage screening (AABR stage) before full audiological follow up and the AABR-only approach would have generated 72 infants for second stage. CONCLUSIONS: Testing with the Natus ALGO Model 2e color newborn hearing screener proved to be practical, time-, and cost-efficient. The low initial referral rate would not only save money within our hospital, but serves to keep parental anxiety at a minimum. The high tolerance of ambient noise allowed flexibility in our screening location and timing, improving our ability to screen before discharge. In our setting, the adoption of AABR as our primary screen is more practical and less expensive than TEOAE.

Adult↗

Cross-border health care in the European Union: recent legal implications of 'Decker and Kohll'.

In the European Union a growing number of citizens are receiving medical treatment in a country other than the one in which they are resident. This concerns migrant (frontier) workers, emergency treatment and preauthorized care. Since 1998 a 'new category' can be discerned of persons going abroad without prior authorization on the basis of the Decker and Kohll rulings of the EC Court of Justice. Local payers would, because of the Decker and Kohll judgements, be obliged to reimburse patients who travel abroad to circumvent the existing problems with the authorization rules. During the past years studies within specific so-called Euregions have been performed to analyse cross-border flows and provide some more insight in the practical and health policy consequences of the Decker and Kohll judgements. The abolishment of current preauthorization is pleaded for by many respondents in these studies. Waiting lists form an important motive (in particular in the Netherlands) to consume health care in another Member State (Belgium and Germany). The familiarity with (health care in) Belgium eases the unofficial Decker and Kohll route. However, when some parts of the health care services seem to be more expensive in the other Member State, the patient has to pay the difference. New court cases are pending before the European Court of Justice. These cases raise new issues such as the tenability of 'benefits-in-kind' systems. So far, the Decker and Kohll rulings could be seen as an incentive to enhance access to cross-border health care in border areas.

Belgium↗

New intra-renal graft genes associated with tolerance or rejection.

BACKGROUND: Recipient type mononuclear cells infiltrating kidney allografts have different phenotypes and functions according to the fate of the graft. We hypothesized that different genetic programs were involved in rejected or accepted tissues and thus, transcripts that correlated with the clinical status could be identified by a differential expression strategy. This strategy was applied to miniature swine class II matched, class I disparate kidney grafts, which are accepted in recipient animals treated for 12 days with Cyclosporin A (CsA). METHODS: The mRNA differential display RT-PCR technique (DDRT-PCR) was used to detect clinical status-specific transcripts. cDNA templates for this analysis were derived from biopsies of accepted (CsA treated) and rejected (untreated) kidney grafts 8 days post-transplantation. RESULTS: A first screening procedure identified 23 PCR products differentially amplified in either tolerant or rejector samples. Nucleotide sequence of these partial transcripts showed that 11 out of 23 (48%) sequences had unknown open reading frames while 12 had substantial homology to known sequences. To validate the approach, rejection-associated (RA) cDNA 1 (RA-1) was characterized further. The results indicated that RA-1 is the porcine equivalent of secreted protein acidic and rich in cysteine (SPARC). Expression studies demonstrated that upregulation of SPARC gene transcription preceded other indicators of kidney dysfunction and correlated with the extent of graft infiltration. CONCLUSION: DDRT-PCR appears to be a powerful technique to identify genes differentially expressed in grafted tissues that correlate with tolerance or rejection. One of the gene transcripts identified through this method, SPARC, may be a reliable marker of tissue injury consequent to cellular infiltration and rejection.

Animals↗

Satisfaction and use of prenatal care: their relationship among African-American women in a large managed care organization.

BACKGROUND: Although many more mothers of almost all ethnic groups began prenatal care in the first trimester during the last decade, a significant number of low-income and minority women still fail to obtain adequate care in the United States-a failure that may be related to their dissatisfaction with the prenatal care experience. This study sought to examine the relationship between satisfaction with care and subsequent prenatal care utilization among African-American women using prospective methods. METHODS: A sample of 125 Medicaid and 275 non-Medicaid African-American adult women seeking care through a large Midwest managed care organization were interviewed before or at 28 weeks' gestation at one of two prenatal care sites. Women were interviewed about personal characteristics, prenatal care experience, and ratings of care (satisfaction). Information about subsequent use of prenatal care was obtained through retrospective medical record review after delivery. Univariate and multivariable analyses examining the relationship between women's satisfaction and prenatal care use were conducted using a dichotomous measure of satisfaction and a continuous measure of utilization. RESULTS: Women were highly satisfied with prenatal care, with an overall mean satisfaction score of 80.3. Non-Medicaid women were significantly (p < 0.05) less satisfied with their prenatal care (mean score, 79.1) than Medicaid women (mean score, 82.8), and the latter had significantly fewer visits on average than the former subsequent to the interview. Analyses showed no significant difference in subsequent utilization according to whether a woman had a high versus low level of satisfaction at the prenatal care interview. CONCLUSIONS: This study challenges the assumption that improving a woman's satisfaction with care will lead to an increase in the adequacy of her prenatal care utilization. Since this study was limited to African-American women and is the first prospective study of women's satisfaction with care and prenatal care utilization, the negative findings do not yet settle this area of inquiry. Monitoring women's satisfaction with prenatal care in both managed care and fee-for-service settings and working to improve those aspects of care associated with decreased satisfaction is warranted.

Adolescent↗

Day care for Alzheimer's disease. Profile of one program.

In its first year of operation, the Alzheimer's Disease Day Treatment Program has proved beneficial to both patients and families. The program has aided family members in acceptance of the illness through education, in practical problem solving through information, and in reduction of the burden of care through respite. Family members have learned how to manage their feelings and have increased their insight into the determinants of patient behavior. In learning to cope with the illness, they have helped both themselves and the patient.

Aged↗

Engaging substance abusers after centralized assessment: predictors of treatment entry and dropout.

High attrition continues to be an important issue for substance abuse treatment providers. This study examined factors contributing to treatment entry and dropout after referral from centralized assessment. Univariate analysis showed that individuals with a shorter wait after assessment were more likely to attend an initial treatment appointment, while those who reported a history of physical or sexual abuse or were on probation were significantly more likely to drop out of treatment early. Multivariate analysis revealed, first, that persons with a comorbid psychiatric diagnosis and those referred to outpatient rather than residential care were less likely to enter treatment; and, second, that persons on probation and with a history of physical or sexual abuse were more likely to be early treatment dropouts. Findings suggest that decisions to seek help and to accept help are distinct, and that program factors play a substantial role in treatment engagement and retention.

Adult↗

The combined effects of treatment intensity, self-help groups and patient attributes on drinking outcomes.

Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were interviewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

Adult↗