The effect of physicians’ remuneration system on the Caesarean section rate: the Uruguayan case

Using data about births from the perinatal information system (PIS) registered in Montevideo (Uruguay), we estimated the probability of having a Caesarian section delivery, controlled by risk factors and the endogeneity of the choice of hospital. In public hospitals in Montevideo there is a fixed payment system, but in private hospitals this procedure has to be paid for separately. In the former, there is no effect on the doctor’s income if he performs a Caesarian, but in the latter there is a positive effect. Empirical evidence shows the probability of a Caesarean section increases with the age of the woman, the presence of eclampsy, pre-eclampsy, previous hypertension, previous Caesarean sections, multiple pregnancies and fetopelvic disproportion, and decreases for multiparous women and women in a public hospital. In fact, the probability of having a Caesarean section in a private institution is almost two times higher than in a public hospital (20% as against 39%). Focusing on women without risk factors, we found that the probability a Caesarian in a public hospital was 11%, but the probability in a private hospital was 25%. We conclude that the remuneration system explains an important part of this difference.     

Ten-year evaluation of hypertension, overweight, cholesterol, and smoking control: the CHAD program in Jerusalem. Community Syndrome of Hypertension, Atherosclerosis and Diabetes

Control of hypertension, overweight, hypercholesterolemia, and smoking is a major objective of the CHAD program, a multifactorial cardiovascular risk factor program built into a family practice, which has operated in a neighborhood of western Jerusalem since 1971. By 1975-1976, there was a significantly larger decrease in risk factors in this population than in a neighboring population receiving ordinary medical care. Follow-up based on clinical records of a cohort of 441 people exposed to the program until 1981 revealed that the mean blood pressures decreased and the prevalence of hypertension continued to decrease between 1976 and 1981, from 12.5 to 9.1%. Prevalence of cigarette smoking among people ages 30 years or more also decreased in this period, mainly due to a decrease in heavy smoking, at a time when national surveys provided no evidence of a smoking decrease in this age group. Effects on overweight and cholesterol were not demonstrated during this period. This 10-year evaluation demonstrates the effects of intervention by primary care practitioners in the framework of a community-oriented program.     

Child health on a dollar a day: some tentative cross-country comparisons

Children living on a dollar a day-the international extreme poverty line-appear to have radically different chances of dying in childhood and being malnourished, depending on the country in which they live. In Kazakhstan, a child living on a dollar a day, has only a 10% risk of being underweight, while the risk facing a child living on a dollar a day in India is nearly 60%. The Kazakh child has a risk of less than 40 per 1000 of dying before his first birthday, while a child living on a dollar a day in Niger faces a risk of nearly 160 per 1000. Countries where mortality and malnutrition risks at a dollar a day are high are not typically those where there are large gaps in child survival and in malnutrition between the poor and better-off. The two concepts of inequality and health risks at the poverty line are not only conceptually distinct-they are empirically distinct too. The large differences between countries in the risks of mortality and malnutrition in childhood beg the obvious question-what accounts for these differences? Some regression results presented in the paper suggest that these differences may be due to differences across countries in levels of per capita expenditure on the health sector. Regressions find that higher levels of per capita public spending on the health sector are associated with significantly lower levels of mortality and malnutrition amongst children living on a dollar a day.     

"Can you spare an organ?": exploring Hispanic Americans' willingness to discuss living organ donation with loved ones

Living organ donation offers a means of overcoming the shortage of viable organs available for transplant: a shortage particularly problematic among Hispanics. One barrier standing between those in need of a kidney and a successful transplant operation is an inability, and often lack of desire, to talk to loved ones about the need for a living donation. With an eye on future intervention approaches, and guided in part by the theory of planned behavior, this research effort sought to explore the factors associated with a willingness to engage in a conversation about a living donation with loved ones. Study 1, a phone survey of Hispanic Americans drawn from a Hispanic surname list, reveals that while upward of 90% of respondents would be willing to offer a kidney to a family member in need, and a similar percentage would be willing to accept a living donation if offered, only about half of respondents would feel comfortable initiating a conversation with family members if the respondent was in need of a living donation. Study 2, a survey of Hispanic American patients currently in need of a living kidney donation, revealed that perceived behavioral control accounted for 60% of the variance in future intentions to initiate a conversation among those who have yet to speak to a family member about becoming a living donor. Moreover, perceived behavioral control mediated the relationship between perceived asking appropriateness and future intentions to initiate a conversation. Lastly, recipient outcome expectations, asking appropriateness, and subjective norms were revealed to be predictive of perceived behavioral control. Implications for future living donor interventions focusing on increasing recipient-initiated conversations are discussed.     

Evaluating cancer clusters

We have had considerable success in identifying cancer causing agents in the workplace using epidemiologic methods. This success had made us very sensitive to the occurrence of cancer clusters among workers in the belief that identification of some common exposure could reveal the presence of a carcinogen and lead to preventive measures. This intense surveillance is both a blessing and a curse. On the one hand, it is a proven way of discovering environmental causes of cancer. On the other, it leads to false alarms or does not always lead to identification of a causal agent. It is easy to demonstrate, using tables of random number 5, how clusters can occur by chance and to demonstrate that when the number of comparisons made in identifying clusters is known there is a basis for their evaluation. Unfortunately, in most instances, when cancer clusters are detected in the workplace the number of comparisons made is unknown and the statistical significance of the cluster cannot be evaluated. Moreover, it is not usually recognized that in this situation when a study is made as a result of discovering a cluster in a particular population, the cases that make up the cluster cannot be included in a data set which tests the hypothesis that a cluster exists. This paper illustrates the above points by actual experiences.     

Infant feeding and women's work in Western Samoa: a hypothesis,some evidence and suggestions for future research

This paper argues that a key reason for the decline in the age of weaning in 3rd world countries may be an increasing workload for women associated with increasing involvement in the cash economy. This hypothesis is considered in light of data collected in an anthropological field study of a rural village in Western Samoa. Methods used were a village census, a household survey with fertility histories and questions on household economy, a questionnaire on breastfeeding, key informant interviews, observations made during residence in the village, and archival research. The ethnographic data suggest the possibility of a causal relationship between a decline in the age of weaning and an increasing workload for women in Western Samoa. In addition, other factors thought to account for a decline in the age of weaning, such as bottle feeding and urbanization, are unimportant in rural Western Samoa.     

The glycaemic index: importance of dietary fibre and other food properties

An increasing body of evidence suggests that a low-glycaemic-index (GI) diet has a therapeutic as well as a preventive potential in relation to the insulin resistance syndrome. The implementation of a low-GI diet, however, will require an extended list of low-GI foods to be available on the market. The tailoring of low-GI bread products offers a particular challenge due to their generally high GI and abundance in the diet. Low-GI bread products can be tailored by, for example,enclosure of cereal kernels, sour dough fermentation and/or addition of organic acids, or use of cereal genotypes with elevated contents of amylose or f-glucans. Low-GI cereal foods appear to vary in effect on 'second-meal' glucose tolerance in healthy subjects. In addition to the slow-release properties of such foods, the content of dietary fibre appears to play a role. The low glycaemia to starch in a pasta breakfast (GI 54) promoted a higher glucose tolerance and lowered triacylglycerol levels at a standardized lunch ingested 4 h later, compared with a white-wheat-bread breakfast (GI 100). The metabolic benefits of the low GI properties per se have been demonstrated also in the longer term. Thus, a reduction in dietary GI improved glucose and lipid metabolism and normalized fibrinolytic activity in type 2 diabetics, while maintaining a similar amount and composition of dietary fibre. However, the higher dietary fibre content frequently associated with low-GI foods may add to the metabolic merits of a low-GI diet. Consequently, a low-GI barley meal rich in dietary fibre (GI 53) improved glucose tolerance from evening meal to breakfast, whereas an evening meal with pasta had no effect (GI 54). The exchange of common high-GI bread for low-GI high-fibre bread, as the only dietary modification, improved insulin economy in women at risk of type 2 diabetes. These results are in accordance with epidemiological evidence of a reduced risk of type 2 diabetes with a low-GI diet rich in cereal fibre. It is concluded that low-GI cereal foods developed should preferably be rich in dietary fibre.     

Child and adolescent obesity in the 21st century: an Australian perspective

The early 21st century has seen the development of a global epidemic of obesity in both developed and developing countries. In Australia at least one in five children and adolescents are overweight or obese, with rapid rises in prevalence apparently continuing. Similar trends are seen in other countries. Child and adolescent obesity is associated with both immediate and long-term medical and psychosocial problems, including a clustering of risk factors for the development of cardiovascular disease and diabetes. Thus, obesity poses a major health problem for the paediatric population. Major environmental and societal changes have led to a decrease in physical activity, a rise in sedentary behaviour and the consumption of high fat and high-energy foods, all in turn influencing the development of obesity. Effective management involves a multimodal approach with a developmentally aware approach, involvement of the family, a focus on healthy food choices, incorporation of physical activity and a decrease in sedentary behaviour all being important. Ultimately, however, the obesity epidemic requires a major focus on primary prevention. Australia has a national strategy for the prevention of overweight and obesity that depends upon intersectoral and intergovernmental cooperation, supported by adequate resourcing and significant community ownership.     

Effects of economic change on male morbidity in neighbouring industrial and rural municipalities in northern Sweden.

STUDY OBJECTIVE--The aim was to investigate the health effects of economic changes in a rural and industrial community. DESIGN--This was a historical cohort study with retrospective information on exposure and information on health outcome from a mailed questionnaire (response rate 82.5%). SETTING--An industrial and a rural community in northern Sweden. PARTICIPANTS--Participants included all men born in a rural community and a random sample of men born in a neighbouring industrial community 1915-1924 and alive in 1984 (N = 1989). MAIN RESULTS--Morbidity was higher in the cohort born in the rural municipality in which more profound changes in the socioeconomic structure had occurred. Even when taking such factors as childhood deprivation, migration, socioeconomic status, early retirement, unemployment, and single living into consideration, most of the differences in morbidity in the two municipalities still remained. However, the changes in employment conditions alone do not appear to explain the differences in morbidity that were found. CONCLUSION--The higher morbidity in the rural community indicates a health effect of the profound economic changes in that community but this difference cannot be explained by crude indicators of exposure to migration, unemployment, and other indicators of economic change.     

Tendon transfers to restore hand function following peripheral nerve injury in the arm

Three patients, a woman aged 33 years, a man aged 42 and a woman aged 66, had a loss of hand function. This was due to denervation of a peripheral nerve, in essence the radial, ulnar and median nerves respectively. In the first two cases this was caused by trauma and in the third by compression neuropathy. The problems were loss of wrist and finger extension (a dropping hand) in the first, loss of intrinsic muscle function and thumb adduction in the second and loss of opposition in the third patient. Tendon transfers were performed by diverting a tendon insertion of a still functional muscle to another tendon to correct the disturbed mechanical balance in the affected upper extremity. After initial immobilisation during several weeks intensive rehabilitation was started. All patients had improvement of range of motion and power in the affected wrist and fingers. In this way a better daily function and resumption of work were accomplished.     

Clinical applications of hypnotherapy

Hypnosis has been used as a therapeutic tool for centuries, but only in the past 50 years have the clinical applications been delineated. As evident in the medical literature, the use of hypnosis by the medical community has increased, partly as a result of a growing awareness of hypnotherapy as an available treatment modality, and also as a result of major improvements in research methodology through strict standardization. Hypnotherapy, once considered to be limited to entertainment, has now proven useful in the treatment of a wide variety of medical illness. Two cases of the use of hypnosis are presented. In the first case, hypnosis is used to alleviate pain in a gravid patient in sickle cell crisis. In the second case, hypnosis is used for desensitization of dental phobia in a 27-year-old women. The historical, theoretical, and clinical applications of hypnosis are reviewed.     

Effects of fish-oil ingestion on cardiovascular risk factors in hyperlipidemic subjects in Israel: a randomized, double-blind crossover study

Effects of a daily fish-oil supplement on serum lipids, apolipoproteins, and some platelet functions and hemorheologic variables were examined in 27 hyperlipidemic subjects in a randomized, controlled, double-blind, crossover fashion with an identically encapsulated vegetable oil serving as the control treatment. Despite the habitual high linoleic acid intake of the study population, significant incorporation of n-3 (omega-3) fatty acids into the serum, platelet, and erythrocyte lipids was observed after the fish-oil supplement. Ingestion of fish oil resulted in a 40% decrease in the triglyceride concentration, a 12% increase in HDL cholesterol, and a significant decrease in plasma viscosity, whereas the vegetable-oil placebo had no significant effect. We conclude that a moderate intake of fish oil (15 g/d) is a feasible treatment for hypertriglyceridemia even in patients with a background of high linoleic acid intake and that it may have a beneficial effect on several cardiovascular risk factors.     

Enuresis in childhood

Enuresis is a frequent reason for consultation in the primary care centres. Although its natural evolution in the majority of cases is towards spontaneous resolution, the negative consequences that can be occasioned in the life of the child and the discomforts that it creates for the family justify our interest in dealing with the question. Our aim is to define the concept of enuresis and its types; to contribute a protocol based on a careful anamnesis and an exploration and a basic analysis of urine to enable us to make an initial selection of those cases that might have a pathological background and thus be susceptible to a more exhaustive study and that in some cases will require a specific treatment depending on the cause. On the other hand, we aim to present a work methodology that is applicable in the great majority of types of enuresis, and which, besides being free of the undesirable effects of some classic treatments, obtains a high percentage of success. Similarly, we aim to contribute a series of basic norms for a correct apprenticeship in starting to control micturition and that could be incorporated in the program of a healthy child.     

One hundred years of the Association of Surgeons in the Netherlands. VIII. Surgical oncology

The Dutch surgical oncologists founded the Dutch Society for Surgical Oncology in 1981 with the aim of providing the best possible level of expertise in the multidisciplinary approach to the treatment of cancer, which at that time was a new development in cancer care. Since then, many developments have contributed to improving the outcome of care for the patient suffering from malignant disease. Surgeons have often played an initiating and pivotal role in these developments. Furthermore, in recent years there has been a strong development in quality awareness. This has led to a greater degree of cooperation in which intensive contacts exist. At the same time developments have taken place in surgical oncology: the care provided has developed from a broadly based care of the patient with a malignancy to care system concentrating on organ systems. As a result of this, the multidisciplinary therapeutic approach to the patient with cancer has been further developed. This might however lead to a fragmentation of oncological care and a loss of identity for the surgical oncologist, who possibly more than any other sub-specialist plays a pivotal role in caring for the patient with a solid malignancy.     

Time-period effects in longitudinal studies measuring average rates of change

Random time-period effects are unexplained increases or decreases in the observed value for all individuals measured at a particular time point in a longitudinal study. They can be caused by learning effects, changes in equipment, personnel and overall subject co-operation. We investigate the consequences of time-period effects in random coefficient regression models, where interest is in the average rate of change (slope) of a continuous outcome. In a study with a single group of subjects, they can lead to conditionally biased estimates of the mean slope and its variance (conditional on the time-period effects). Calculations suggest that the increase in sample size required to maintain a specified precision of the mean slope estimate over repeated studies may be substantial. In a study with a concurrent control group, however, time-period effects do not distort the expectation, estimated variance or the distribution of the difference between the mean slopes. With missing data, in addition to time-period effects, an unbaised estimate of a single mean slope remains problematic, but one can use standard maximum likelihood techniques to obtain consistent estimators of the difference in mean slopes and its variance. This suggests the importance of a concurrent control group when potential time-period effects are of concern.     

Risk society and epidemiological risk

The concept of risk entails a broad discussion, ranging from a more general approach, seeking to contextualize it in the dynamic of societal change, to a more specific approach in the field of health, particularly in epidemiological studies on associations. The term "risk" has appeared with increasing frequency in medical journals in the last three decades, but the phenomenon is not exclusive to health and is permeated by the diversity of a notion that hides a conceptual gap. Given this diversity, the current paper begins with a literature review to systematize the discussion of risk. The result is organized in three sections: 1) an overview of the discussion on risk within the debate on societal change in the transition from modernity to a new phase of social organization; 2) a summary of various uses of the risk notion in health knowledge; and 3) the establishment of the epidemiological concept of risk and its link to clinical medicine.     

Expression of the cystic fibrosis gene in the lungs

Cystic fibrosis (CF) is one of the most common hereditary diseases with a potentially lethal outcome. CF is caused by mutations in a gene on chromosome 7 that encodes for a polypeptide called 'cystic fibrosis transmembrane conductance regulator' (CFTR). Pulmonary complications in CF are a direct consequence of a fault in the production or function of CFTR. The consequences of these faults are a change in the viscosity and volume of the air-surface liquid in the airways and possible malfunctioning of the immunological defence system. The result is stasis of mucus and obstruction of the smaller airways. Secondary to this process, a (chronic) infection with an uncontrolled inflammatory response, leads to destruction of lung tissue and a reduction in lung function. Mutations in CFTR can be classified in five types, which reflect the level of production or the function of CFTR. This classification permits discrimination between mild and severe mutations. The clinical image and the course of CF are often related to the combination of mutations present. This may explain, in part, why some CF patients are diagnosed at a later age with a normal sweat test and a clinical image that is predominantly limited to respiratory symptoms.     

Health organizations from the perspective of complex care system

The construction of new practices of care presupposes a new look for the health organizations. The objective of this text is to interpret the complexity theme in health and in Nurse fields in the care systems perspective, in order to promote a reflection of the practices of care in the health organizations context. The complex thought brings a new way to conceive the action and the human condition under different perspectives. It appears as a possibility for the visualization of a care system as a complex system in your structures and properties, in the movements of interretroactions in the organizational spaces and in possible auto-organizers processes. It is hoped a transforming action of the health organizations that considers the ambiguities, the uncertainties and the contemporary social dynamics for a healthier living.