To market! To market! A new dawn for community care?

The public sector in Britain has been subjected to over a decade of major reform aimed at breaking up public service monopolies, at containing costs while at the same time opening services up to greater consumer choice. Health and social services have not been exempt from this revolution in the organization and management of public sector services. The long-standing policy of care in the community is being subjected to market principles and the introduction of a ‘contract culture’ very similar to the NHS reforms introduced in 1991. This paper reviews the origins of these developments in the doctrines of ‘new public management’, a movement which has proved attractive to policy-makers in many countries. Local authority social services departments have been identified as the lead agency for the development of a mixed economy of care following a review of community care policy by the government's health adviser, Sir Roy Griffiths, and a subsequent white paper. This paper examines the limited empirical evidence available on how managers and providers are meeting the challenge bestowed upon them, and concludes that most authorities are moving ahead cautiously if at all. Only a handful of authorities studied have embraced the reforms with any degree of enthusiasm. The paper concludes with an assessment of the reforms from two perspectives: a pessimistic one and an optimistic one. There are many worrying features of the reforms, not least among these being a lack of clarity over their intended purpose. Tensions and contradictions are plentiful, which places in jeopardy the certainty of the reforms in becoming user led rather than provider driven. A more optimistic scenario is that the changes are leading to a loosening up of services and practices which have often suffered from sclerotic tendencies, paternalism and sometimes complacency. If the reform process is skilfully handled and not rushed and if the ends are clearly established and communicated then users and carers could prove to be the principal beneficiaries.     

Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding

The aim of this study was to assess the accuracy of technetium 99m-labeled red cell scintigraphy in localizing the site of lower gastrointestinal bleeding. The outcome of 203 patients undergoing technetium 99m-labeled red cell scintigraphy was reviewed, and the scan result was compared with the true site of bleeding. The true site of bleeding was determined by other methods including angiography and surgical pathology. Fifty-two scans (26%) were positive and indicated a specific site of bleeding. A definitive bleeding site was identified in 22 patients by other means and correlated with the technetium scan in only 9 cases. The nuclear scan was incorrect in the remaining 13 cases, implying a localization error of 25% (13 of 52). A subgroup of 19 patients with a positive scan underwent a surgical procedure directed by the nuclear scan. Eight of these 12 patients had incorrect surgical procedures based upon findings of more definitive tests, indicating a surgical error of 42% (8 of 19). We conclude that the technetium 99m-labeled red cell scan's ability to accurately localize the site of lower gastrointestinal bleeding is limited. Furthermore, performing a surgical procedure that relies exclusively on localization by red cell scintigraphy will produce an undesirable result in at least 42% of patients.     

Topical steroid use in the treatment of ocular alkali burns

BACKGROUND—Ocular alkali burns can be associated with a poor visual outcome. The release of collagenases and proteases after the injury leads to corneoscleral melting. The role of topical steroids in such patients is controversial as they have been postulated to exacerbate corneoscleral melting.
METHODS—30 patients were reviewed retrospectively after admission to King's College Hospital with alkali burns between 1990 and 1993. All patients were treated with an intense and prolonged regimen of topical steroids and topical and systemic vitamin C.
RESULTS—22 patients had mild injuries and eight had severe injuries as estimated by the Roper-Hall grading system. 23 patients were treated with topical steroids for > 10 days and 22 patients were treated with topical vitamin C for more than 10 days. One patient with a severe injury developed corneoscleral melting.
CONCLUSION—Prolonged treatment with topical steroids when used in conjunction with topical vitamin C is not associated with corneoscleral melting.

     

The ureteral access system: a review of the immediate results in 43 cases

The ureteral access set was used 43 times during an 18-month period between 1984 and 1985. Stones lodged throughout the ureter and in the renal pelvis were extracted with a success rate of 51 per cent. Of the upper tract strictures 92 per cent were dilated successfully. Filling defects were diagnosed in 88 per cent of the cases. Foreign bodies were retrieved, Double-J stents were placed and biopsies were successful in each case. Ureteral perforation in 28 per cent of the cases was caused by the dilator in 8 of 12 (19 per cent over-all). The technique and short-term results are discussed. Long-term followup data are not yet available.     

Epithelial secretion of vinblastine by human intestinal adenocarcinoma cell (HCT-8 and T84) layers expressing P-glycoprotein.

P-glycoprotein expression was demonstrated in two human intestinal adenocarcinoma cell-lines (HCT-8, ileocaecal and T84, colonic) by immunoprecipitation of a 170-180 kDa protein with monoclonal antibody JSB-1. Both HCT-8 and T84 formed functional epithelial cell layers of high transepithelial electrical resistance (greater than 700 omega.cm2) when grown on permeable matrices. These epithelial layers demonstrated vectorial secretion (net vinblastine fluxes in the basal-to-apical direction of 0.135 and 0.452 pmol h-1 cm-2 in HCT-8 and T84 cell layers, respectively, from bathing solutions containing 10 nM vinblastine). These vectorial vinblastine secretions were sensitive to inhibition by verapamil. Passive transepithelial vinblastine permeation was limited by the presence of intercellular (tight) junctions, as demonstrated by the high transepithelial electrical resistance, and verapamil increased this passive vinblastine permeation concomitant with a reduction in the electrical resistance. Cellular vinblastine loading was significantly greater from the basal side, and this was also susceptible to inhibition by basal verapamil. The demonstration of vectorial transport of vinblastine in human intestinal colonic adenocarcinoma cell layers is direct evidence in favour of the hypothesis that the function of mdr1 in epithelial from the gastrointestinal tract is to promote detoxification by a process of epithelial secretion. This study also highlights that cellular vinblastine accumulation depends not only upon P-glycoprotein function, but also upon differential apparent membrane permeabilities and the presence of intercellular (tight) junctions that may restrict drug permeation and cellular accumulation to apical or basal membrane domains.     

Audiologic evaluation of the otitis media patient

Because of the complexity and variability in the expression of otitis media, its effects on auditory function are diverse. The various influences of otitis media on auditory function are described within this article, including acoustic reflex, audiometry, and tympanometry.     

The impact of lower urinary tract symptoms on general health status and on the use of prostatectomy

Our objective was to determine the extent to which lower urinary tract symptoms affect the general health status of men and contribute to the decision to undergo surgery. A cross-sectional population survey using postal questionnaires was conducted in the North West Thames health region, followed by a prospective cohort study of men undergoing prostatectomy (North West Thames and Oxford regions). The subjects in the first survey were 221 men aged 55 and over with previously reported mild, moderate or severe urinary symptoms; subjects in the second study were 388 men undergoing prostatectomy. Main outcome measures were selfreported symptom severity, bothersomeness and general health status (Nottingham Health Profilie, Part 1). The response rate among eligible responders in the population survey was 85.7%. Increasing symptom severity was associated with worsening NHP scores for energy, emotional reactions, sleep and physical mobility (p<0.01). Increasing bother-someness of symptoms was associated with emotional reactions, sleep and pain (p<0.05). Men undergoing surgery reported worse health status than men in the population with the same severity of symptoms as regards emotional reactions, energy and pain. For a given level of symptom severity, the impact of those symptoms on aspects of a man's general health status may be the determinant of seeking and undergoing surgery. Greater understanding of the factors that affect a man's response to his symptoms is needed in interpreting the decision to seek and accept treatment.     

闭经

闭经指育龄期妇女月经未来潮。导致闭经的病因很多,有病理性和生理性两类。病理性原因导致的闭经多见于原发性闭经,解剖原因所致的闭经少见但也很重要。妊娠和哺乳期闭经属生理性闭经。闭经通常分为原发性和继发性闭经两种。原发性闭经指16岁时仍无月经来潮,而继发性闭经是指≥6个月无月经来潮。导致闭经原因常常多个混杂,所以区别两者的实际意义不大。导致闭经的内分泌因素包括:多囊卵巢综合征、紧张和劳累、体重相关、高泌乳素血症、心理性疾病、全身性疾病如:肾功能衰竭、药物因素、卵巢早衰、垂体缺血性坏死、原发性下丘脑-垂体-卵巢(H…