Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these concepts. Based on research instruments administered to a sample of 91 health sector decision-makers in 17 districts of Pakistan, this study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as "decision space"), institutional capacities, and accountability to local officials. Composite quantitative indicators of these three dimensions were constructed within four broad health functions (strategic and operational planning, budgeting, human resources management, and service organization/delivery) and on an overall/cross-function basis. Three main findings emerged. First, district-level respondents report varying degrees of each dimension despite being under a single decentralization regime and facing similar rules across provinces. Second, within dimensions of decentralization-particularly decision space and capacities-synergies exist between levels reported by respondents in one function and those reported in other functions (statistically significant coefficients of correlation ranging from ρ=0.22 to ρ=0.43). Third, synergies exist across dimensions of decentralization, particularly in terms of an overall indicator of institutional capacities (significantly correlated with both overall decision space (ρ=0.39) and accountability (ρ=0.23)). This study demonstrates that decentralization is a varied experience-with some district-level officials making greater use of decision space than others and that those who do so also tend to have more capacity to make decisions and are held more accountable to elected local officials for such choices. These findings suggest that Pakistan's decentralization policy should focus on synergies among dimensions of decentralization to encouraging more use of de jure decision space, work toward more uniform institutional capacity, and encourage greater accountability to local elected officials.     

Counselling teenage girls on problems related to the 'protection of family honour' from the perspective of school nurses and counsellors

Approximately 1,500 young immigrant women living in Sweden sought help from various public organisations during 2004 due to problems related to Protection of Family Honour (PFH). Often they seek help from school nurses and counsellors. Information on how the school nurses and counsellors manage this complex PFH phenomenon is limited in Sweden. The aim was to generate a theoretical model that illuminates the experiences of school counsellors and school nurses counselling teenage girls, who worry about problems related to protection of family honour. Data were collected through individual interviews of the school welfare staff. The study subjects included welfare staff from six upper-secondary schools consisting of four nurses and six counsellors. Grounded theory methods were used to generate new knowledge as this is a new field of research. The staff's main goal was to provide the best support and help for the teenage girls. In addition, they wanted to be true to their professional ethics and values. However, this was difficult and created professional dilemmas because some teenage girls prevented them from doing what they thought was needed to support the teenage girls and protect them from violence. As a result, staff sometimes felt hampered, unable to help or able to help only in ways hidden from the teenage girls' families.     

A retrospective comparison of BMI changes and the potential risk factors among schizophrenic inpatients treated with aripiprazole, olanzapine, quetiapine or risperidone

The objective of this study was to evaluate weight gain and its potential risk factors among different second generation antipsychotics (SGAs). The study was conducted for Korean inpatients with schizophrenia in a university hospital in Seoul, between Jan 2000 and Dec 2007. Data were collected by reviewing the medical records of the patients, who were prescribed to one of the SGAs among aripiprazole, olanzapine, quetiapine or risperidone. The changes of weight and body mass index (BMI); risk of clinically significant weight gain (> 7% gain to initial weight) and their associations with various clinical characteristics of such patients were analyzed. Five hundred and eighty-eight (588) and 294 subjects treated with one of the four SGAs for a duration of 1 month and 2 months were included, respectively. Olanzapine showed significantly greater weight and BMI increase at month 1 (p = 0.028 for weight; p = 0.019 for BMI) and month 2 (p = 0.032 for weight; p = 0.029 for BMI) than others. Females showed greater BMI increase change (0.70 ± 0.91 kg/m², p = 0.008) and were also more likely to experience clinically significant weight gain (odd ratio = 1.846, 95% CI = 1.098 to 3.105, p = 0.021) at month 1.Younger patients (< 45 years old) had significantly greater weight and BMI increase at both months 1 and 2. Younger patients also showed greater risk for clinically significant weight gain at month 2 (odd odd ratio = 2.567, 95% CI = 1.196 to 5.508, p = 0.016). Low baseline BMI (< 25 kg/m²) was associated with greater weight gain at month 1 (1.92 ± 2.29 kg, p < 0.001) and month 2 (4.07 ± 3.56 kg, p < 0.001) and BMI increase at month 1 and month 2 (p < 0.001 for both). Patients with low baseline BMI showed higher risk of clinically significant weight gain at both months 1 and 2 (p< 0.001 for both). Olanzapine was shown to have higher metabolic risk than other SGAs in inpatients with schizophrenia. The individual's own clinical characteristics also exerted influence on weight gain effects of SGAs. Younger patients with lower baseline BMI were under greater risk of antipsychotic-induced weight gain. More studies are required to verify the role of gender on weight gain.     

Teaching diagnostic approach to a patient through cinema

Films are produced with the aim of entertaining people, but recently there has been increasing use of films to educate medical trainees about various disorders, symptoms of these disorders, patient–therapist interactions, and various other medical and psychiatric issues. Discussions in academic circles have moved from criticism of negative portrayals of mental illness in earlier films to their use in teaching sessions. Films can be used either in full length or clip format to conduct training modules. Use of the film Stigmata to train residents about diagnostic dilemmas and taking a diagnostic approach to patients is discussed.     

A rare actinomycosis of humerus: an unusual location and a diagnostic dilemma. A case report

Background Isolated actinomycosis of the humerus is a very rare entity. Method A 30-year-old male had an erythematous plaque with a pus-(minimal) discharging sinus over left lower arm. The patient had no discharge of sulphur granules from the sinus. The patient had raised ESR with a single lytic lesion with minimal sclerosis and inconspicuous periosteal reaction on radiographs. Such atypical clinical and radiological features lead to initial wrong diagnosis of tuberculosis. A diagnosis of Actinomycosis of humerus became possible after demonstration of filamentous bacilli in culture and on histopathology from the sulphur grains obtained by open biopsy. Result The patient recovered completely after administering PenicillinG 24 million units intravenous for 7 days followed by 1.2 g of oral amoxicillin in three divided doses for 3 months and did not show any recurrence during last 2 years of follow up. Conclusion Surgeons should be aware of this rare entity and difficulty in its diagnosis due to its variable manifestations, including confusion with highly endemic tuberculous infection. Awareness of full spectrum of the diseases and careful evaluation in individual cases will expedite diagnosis and avoid unnecessary surgical interventions. No financial or any otherwise support has been received in any regard from any organization or institution for this case report titled “A rare actinomycosis of humerus: an unusual location and a diagnostic dilemma—a case report.” All authors have contributed to the study and publication of this case report and agree in congruence to the same.     

Experience of moral distress among pediatric surgery trainees

Purpose

The aim of this study was to identify and qualify the ethical dilemmas faced by pediatric surgery trainees.

Methods

An online survey was sent to pediatric surgery trainees graduating between 2005 and 2008. Consent was obtained, and study investigators were blinded to the identity of the respondents during data analysis.

Results

Of the 40 respondents, only 59% felt they had received adequate training in bioethics to handle ethical issues pertaining to the care of critically ill children. Although 83% of respondents routinely participated in palliative care discussions, 30% of respondents desired to have more opportunities to discuss end-of-life issues with their staff. Moral conflicts were resolved through direct discussions with the medical staff, family, or friends. Despite the presence and awareness of institutional policies on ethical behavior, 58% of respondents did not believe that ethical conflicts were resolved as a result of these policies, whereas 31% of respondents felt that reporting of unethical conduct would result in personal reprisals.

Conclusion

Pediatric surgery trainees face ethical and moral conflicts, but some are fearful of reprisals if these concerns are reported. A neutral forum to raise such issues may facilitate open discussions and eventual resolution of these conflicts.     

Early adolescent outcomes of institutionally deprived and non-deprived adoptees. III. Quasi-autism

BACKGROUND: Some young children reared in profoundly depriving institutions have been found to show autistic-like patterns, but the developmental significance of these features is unknown. METHODS: A randomly selected, age-stratified, sample of 144 children who had experienced an institutional upbringing in Romania and who were adopted by UK families was studied at 4, 6, and 11 years, and compared with a non-institutionalised sample of 52 domestic adoptees. Twenty-eight children, all from Romanian institutions, for whom the possibility of quasi-autism had been raised, were assessed using the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) at the age of 12 years. RESULTS: Sixteen children were found to have a quasi-autistic pattern; a rate of 9.2% in the Romanian institution-reared adoptees with an IQ of at least 50 as compared with 0% in the domestic adoptees. There were a further 12 children with some autistic-like features, but for whom the quasi-autism designation was not confirmed. The follow-up of the children showed that a quarter of the children lost their autistic-like features by 11. Disinhibited attachment and poor peer relationships were also present in over half of the children with quasi-autism. CONCLUSIONS: The findings at age 11/12 years confirmed the reality and clinical significance of the quasi-autistic patterns seen in over 1 in 10 of the children who experienced profound institutional deprivation. Although there were important similarities with 'ordinary' autism, the dissimilarities suggest a different meaning.     

Depression of contractility in isolated rabbit myocardium following exposure to iron: Role of free radicals

The mechanism of acute iron cardiotoxicity was investigated in isometrically contracting left atrial strips and right ventricular papillary muscles isolated from rabbit hearts. A 90-min exposure to iron (1.8 mm; as ferrous sulfate) reduced the peak-developed tension and the maximal rate of tension development. The presence of either N-acetylcysteine (20 mm), superoxide dismutase (2000 units/ml), or mannitol (5 mm) prevented this depression of contractility. Catalase (30,000 units/ml) was not protective against the effects of iron. Iron did not decrease myocardial adenosine triphosphate or creatine phosphate contents. The force-frequency relationship (positive staircase phenomenon) was examined in the absence and presence of iron. Iron did not reduce the positive inotropic response evoked by increasing the stimulation frequency, but at higher frquencies iron prolonged the time from peak tension to 90% relaxation. We conclude that acute iron cardiotoxicity may be mediated by free radical generation and does not involve impairment of myocardial high energy phosphate production.