Challenges facing providers caring for HIV/HCV-coinfected patients

Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.     

No benefits from combining chloroquine with artesunate for three days for treatment of Plasmodium falciparum in Guinea-Bissau

The use of a combination of chloroquine and artesunate has been suggested for treatment of malaria in Africa. We used concomitant as well as sequential medication with these 2 drugs in relation to each drug separately for children infected with Plasmodium falciparum in Guinea-Bissau from March 2000 to November 2001. By block-randomization, 474 children with symptomatic malaria were divided into 4 groups and given either a total of 8 mg artesunate per kg bodyweight for 3 d, a total of 25 mg chloroquine base per kg bodyweight for 3 d, both drugs concomitantly for 3 d, or both drugs in sequence. All children were followed weekly for 5 weeks. On day 28, parasites had been detected in 40% of the children who were treated with artesunate only compared with 21% treated with chloroquine, 20% treated with artesunate in combination with chloroquine, and 16% treated with artesunate and chloroquine in sequence; on day 35 the corresponding percentages were 48%, 29%, 27%, and 24%, respectively. The outcome of the combination of chloroquine and artesunate in the doses studied was similar to the outcome of chloroquine monotherapy regardless of whether the 2 drugs are given concomitantly (relative risk [RR] = 0.93, 95% CI 0.56-1.53, P = 0.76) or in sequence (RR = 0.78, 95% CI 0.47-1.28, P = 0.32). Thus, neither an antagonistic, an additive, or a synergistic effect of the 2 drugs was indicated.     

Getting research into practice: facing the issues

The translation of research into practice is currently a high-profile issue in the NHS. A number of regions have undertaken work in this area. Reports on a project that is part of the Anglia and Oxford Regions's "getting Research into Practice" (GRiP) initiative. The work focuses on the use of steroids in pre-term delivery, a procedure that medical evidence suggests can reduce neo-natal mortality and morbidity. Presents a number of findings which suggest that getting research into practice does not merely rest on the availability of well-researched evidence.     

Challenges facing occupational health services in the 21st century

The mission and tasks of occupational health services are reviewed in the context of the global megatrends of productivity increase, population overgrowth, and the implications of changes in the technology of information and communication. Current trends in attempts to achieve harmonization with respect to the concept and tasks of occupational health services in the European Union are described, along with the basic features of occupational health services as a human service organization with implications for the setting of objectives and criteria for assessing quality and performance and ethics. The need to adopt a quality-focused approach to occupational health service programs is emphasized, and some of the inhibitions and obstacles to quality work are mentioned. The need for professional commitment to develop and implement quality concepts is outlined. Evidence-based health care in the setting of occupational health services and some salient aspects of professional ethics in the 21st century are commented on.     

新世纪医院面临的挑战与对策

作者首先阐述了新世纪医院面临的挑战：一是社会保障制度改革对医院的影响；二是中国加入WTO后对我国医院产生的影响；三是人们需求多样性对医院建设的影响。其次提出了新世纪医院的发展策略；（1）树立新的理念；（2）强化四个意识，即管理意识、竞争意识、服务意识、创新意识；（3）医院建设要注重系统性，即以市场和战场为导向调整学科布局，适应市场需求抓好人才队伍建设，以新的质量观抓医疗质量建设；（4）建立灵活高效的管理机制，即建立快速高效的决策程序、建立以人为本的管理机制、以市场经济的规则改革分配机制，政府对非营利性医院要解决资金补偿问题。     

Recognising and countering the potential barriers to success in international public health collaborations

International collaborations can provide benefits for the surveillanceof communicable diseases. They also provide a range of challengeswhich must be addressed for a project to succeed. This paperhighlights some of these challenges and their solutions by drawingon the experiences of the scientific coordinators of two verydifferent collaborations. Although there are potential barriersto creating international collaborations, they are not insurmountable.It is our belief that the benefits of these networks far outweighany difficulties.     

Challenges facing the United States of America in implementing universal coverage

In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features – health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies – remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes – for the assessment of the cost–effectiveness of pharmaceuticals, health services and technologies – comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorité de Santé in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was – and remains – weakened by a lack of cross-party political consensus. The ACA’s performance and its resulting acceptability to the general public will be critical to the Act’s future.     

Challenges facing nurses' associations and unions: a global perspective

Nurses are at the heart of every country's health care system. What sort of problems do they face at work? What are the coping strategies that they and their organizations pursue? Drawing on the findings of a unique global survey of nurses' associations and unions, the authors provide clear answers to these and related questions at a time when population ageing, epidemics, privatization and understaffing are putting heightened pressures on health care systems around the world. Interestingly, the priority concerns of nurses' organizations the world over have much in common despite the widely differing national contexts in which they operate.     

Challenges facing teleradiology services across borders in the European union: A qualitative study

RationaleThis paper aims to identify factors that support or impede the introduction and expansion of teleradiology across borders in the European Union (EU), focusing on both those factors acting within countries and those that are specifically cross-border as well as discussing how the current EU legislation impacts on the provision of this type of services.MethodsA qualitative study was developed to explore the issues that arise when implementing teleradiology services across European borders. A total of 12 semi-structured interviews with key actors were conducted, recorded and fully transcribed. These were analysed using thematic analysis.ResultsThe factors supporting provision of new services in teleradiology were increasing demand for reading images in countries with few radiologists; long waiting lists for MRI reading; and new demand for second and sub-specialized reading of images. The obstacles to the introduction and expansion of teleradiology services included uncertainty about liability in case of malpractice, registration of health care professionals, data security, non-standard contracts and quality reporting systems; and health care system and cultural differences. Radiologists identified as positive experiences the chance to learn and improve their skills in a shorter period of time, having flexibility, and sharing knowledge in a network environment. The most frequently reported negative aspect was the inability to interact with referring clinicians. Language barriers were not identified as a constraint. When asked about policy implications and potential recommendations, participants proposed the introduction of EU wide policies on radiologists׳ credentials; greater clarity within the EU on data access and sharing; and minimum quality requirements for teleradiology providers.ConclusionTeleradiology services face several challenges; most can be overcome if those engaging in this type of collaborations are eager to make it a success. However, it would be beneficial to have a transparent European legal framework that clarifies issues related to the registration and licensing of healthcare professionals; clarifies arrangements for data sharing and protection; and specifies liability and means of access to redress. Once this legal framework is in place it should be communicated to regulators, health care professionals and patients in a clear way so that it cannot be undermined or ignored and it truly promotes services of good quality which are beneficial to European citizens.     

Positive prevention: contemporary issues facing HIV positive people negotiating sex in the UK

Over 40,000 people are now living with diagnosed HIV in the UK. The term 'positive prevention' has been coined to describe HIV prevention that focuses on people living with an HIV diagnosis. There is uncertainty, however, about how people with HIV manage risk and how their ability to prevent the transmission of HIV is linked to their mental health and social circumstances. We analysed 44 individual and three group interviews with the people most affected by HIV in the UK: black African heterosexual men and women and gay men (mostly white). We found that participants had similar as well as contextually different needs when it came to negotiating safe sex, assimilating prevention knowledge. The themes that emerged included taking 'additional responsibility' for partners, negotiating with partners who are willing to have unprotected (anal or vaginal) sex, links with mental health, constructing the moral 'other' and power differences. We conclude with a discussion of the priorities for positive prevention for men and women living with diagnosed HIV in the UK.     

Low-dose quinine for treatment of Plasmodium falciparum malaria in Guinea-Bissau

The recommended dose of 10 mg quinine/kg bodyweight 3 times a day for 7 days for treatment of malaria is so high that many patients experience cinchonism. We have earlier obtained good results with 7 days' treatment with 20 mg Quinimax/kg bodyweight divided into 2 daily doses. In order to identify the lowest effective dose, children with symptomatic malaria were treated with quinine twice a day for 7 days. They were assigned to 1 of 3 groups treated daily with 10 mg/kg, 15 mg/kg, or 20 mg/kg bodyweight, respectively; 42, 46, and 34 children, respectively, received treatment and completed 5 weeks of follow-up. The cumulative percentages of all children with parasitaemia during follow-up on day 28 or before were 33%, 13% and 12%, respectively. Treatment with 10 mg quinine salt/kg daily for 7 days gave a significantly higher rate of recrudescence than did treatment with 15 or 20 mg/kg daily. Thus at least 15 mg of quinine salt/kg bodyweight daily should be recommended for treatment of symptomatic Plasmodium falciparum malaria in Guinea-Bissau.     

Collaborative research: benefits and guidelines

Several benefits of collaborative research and guidelines for strengthening collaborative mechanisms have been described here, but the impetus for research and development of competent research teams must come from health professionals themselves. The literature makes it apparent that allied health professionals need to devote a considerable amount of energy and resources to develop a knowledge base for the health-related professions, similar to those in medicine and the biological sciences. Research projects, particularly collaborative ones, can make significant contributions to the body of professional knowledge, the knowledge-generation process, the health care practitioner, and the patient. The results of research should not be judged successful until its ultimate goal (ie, impact on patients and practice) has been measured. In collaborative research, relationships should be based on systems thinking, making networking into a scientific approach--a true partnership approach--which is crucial in dealing with the problems of health care today.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.