Making bureaucracy work

What gives bureaucracy such a bad name? Is it bureaucracy in itself, or the ghosts in the system who, in a million minor drifts, contribute to turning efficiency into red-tape? Undesirable side-effects need not be confused with necessary first-level effects. There is nothing wrong with the bureaucratic system as such. Ultimately we could not work without it as it is the only known way of co-ordinating vast numbers of people to treat mass problems. However, like any tool, it is only as good as the people who use it, and its results are largely linked to the very agendas of the users. Understanding what makes bureaucracy work requires a good look at the implicit biases in the bureaucratic model, mostly seeded by its various founders and theoreticians, as well as tackling pragmatic issues of creating and applying rules--and where and when to change them.     

Nutrient intake and iron status of Australian male vegetarians

OBJECTIVE: The study was designed to investigate the iron intake and status of Australian, male vegetarians aged between 20 and 50 y. DESIGN: Cross-sectional comparison of male vegetarians and age/sex matched omnivores. SETTING: Free-living community subjects. SUBJECTS: 39 ovolactovegetarians, 10 vegans and 25 omnivores were recruited by local advertisement. OUTCOME MEASURES: A 12-d semiquantitative dietary record to assess iron and zinc intake. Iron status was assessed by measurement of serum ferritin and haemoglobin concentrations. RESULTS: Mean (s.d.) daily iron intakes of both the ovolactovegetarians (20.4 (7.7) mg/d) and vegans (22.9 (6.2) mg/d), were significantly higher than the omnivores' intake of 15.8 (4.5) mg/d. Ovo-lactovegetarians and vegans had significantly (P < 0.001 and P < 0.05, respectively) lower serum ferritin concentrations than omnivores: mean (s.d.): 64 (46.9), 65 (49.9) and 121 (72.5) ng/ml, respectively. Significantly more ovolactovegetarians and vegans than omnivores had serum ferritin concentrations below 25 ng/ml and below 12 ng/ml (P < 0.05). A higher proportion of omnivores had concentrations above 200 ng/ml (P < 0.05). The differences in serum ferritin concentrations between the vegetarians and omnivores remained significant even after exclusion of iron supplement users. CONCLUSION: Australian male vegetarians had iron intakes higher than those of omnivores and above recommended levels, but their iron status was significantly lower.     

Contact between people with learning disability and general practitioners: a cross-sectional case note survey.

BACKGROUND: This paper describes primary care consultation rates in a sample of people with learning disability. The study was carried out as part of a wider survey of primary care for this population group in response to concerns over quality of care and debate between general practitioners (GPs) and the local health authority over the need for additional remuneration for caring for people with learning disability. Estimates of consultation rates in the literature to date are conflicting and we sought to provide local data on the number and type of contacts with the primary care teams to inform this debate. METHOD: A primary care case note review was carried out of 112 people with learning disability aged over 18, identified from an administrative sample of 967 people known to health and social services. Contact rates (with practice nurses or GPs) were calculated and indirectly standardized for age using data from the fourth National Morbidity Survey in General Practice (MSGP4). RESULTS: Standardized consultation ratio in men was 156 (95 per cent confidence interval (CI) 142-172), in women was 111 (95 per cent CI 102-121) and for both sexes was 127 (95 per cent CI 120-135). Average contact rate was 4.6 per person per year. Eighty per cent of contacts were with GPs. Eighteen per cent (95 per cent CI 11-25 per cent) of subjects consulted, on average, more than once every two months. Limited information on underlying cause of learning disability and severity was available. Consultation rates were independent of age and sex, and were not increased in people with Down's syndrome or epilepsy compared with the rest of the sample population. Consultation rates were highest in people living in staffed group homes (p = 0.01). The presence of special arrangements between practices and residential facilities did not appear to increase service contact, but this finding is prone to measurement bias. CONCLUSIONS: Contrary to the findings of previous studies, people with learning disability consult primary care teams more frequently than the general population. However, this should not be taken as supporting calls for additional resources without addressing the effectiveness and appropriateness of health care offered.     

The association of diet and thrombotic risk factors in healthy male vegetarians and meat-eaters.

OBJECTIVE: The aim of this study was to assess thrombosis tendency in subjects who were habitual meat-eaters compared with those who were habitual vegetarians. DESIGN: Cross-sectional comparison of habitual meat-eaters and habitual vegetarians. SETTING: Free living subjects. SUBJECTS: One hundred and thirty-nine healthy male subjects (vegans n = 18, ovolacto vegetarians n = 43, moderate-meat-eaters n = 60 and high-meat-eaters n = 18) aged 20-55 y who were recruited in Melbourne. OUTCOME MEASURES: Dietary intake was assessed using a semi-quantitative Food Frequency Questionnaire. The parameters of thrombosis were measured by standard methods. RESULTS: Saturated fat and cholesterol intakes were significantly higher and polyunsaturated fat (PUFA) was significantly lower in the meat-eaters compared with vegetarians. In the meat-eaters, the platelet phospholipids AA levels were significantly higher than in the vegetarians, but there was no increase in ex vivo platelet aggregation and plasma 11-dehydro thromboxane B2 levels. Vegetarians, especially the vegans, had a significantly increased mean collagen and ADP stimulated ex vivo whole blood platelet aggregation compared with meat-eaters. The vegan group had a significantly higher mean platelet volume than the other three dietary groups. However, meat-eaters had a significantly higher cluster of cardiovascular risk factors compared with vegetarians, including increased body mass index, waist to hip ratio, plasma total cholesterol (TC), triacylglycerol and LDL-C levels, ratio of TC/HDL-C and LDL-C/HDL-C and plasma factor VII activity. CONCLUSIONS: Consumption of meat is not associated with an increased platelet aggregation compared with vegetarian subjects.     

The lipophilic properties of angiotensin I-converting enzyme inhibitors do not influence their diffusion through cultured endothelium

The background for these investigations was the discovery that formation of angiotensin II by the renin angiotensin system can take place in extravascular tissues (e.g., cardiomyocytes and neurons) and within single cells. Consequently, the question arose about whether such tissue-based systems might be differentially influenced by angiotensin I-converting enzyme (ACE) inhibitors with distinct physicochemical properties. Therefore, the aim of this study was to investigate how the membrane penetration of various ACE inhibitors depends on their lipophilia. All diacid forms of ACE inhibitors are dissociated at a pH of 7.4 and scarcely extractable into octanol (extraction coefficient < 10%). In contrast, the extraction coefficients of the parent substances showed marked differences in the following order of increasing lipophilia: enalapril = perindopril < captopril = ceranapril < ramipril < quinapril < HOE288 = zofenopril < fosinopril < HOE065. For selected substances, the kinetics of diffusion through a monolayer of cultured bovine aortic endothelium were determined. The diffusion rates (expressed as half lives) of captopril (59.6 min), enalapril (53.4 min), enalaprilat (50.8 min), ramipril (56.9 min) and ramiprilat (51.1 min) are similar indicating: 1) that penetration is independent on lipophilia and 2) that endothelium constitutes no specific barrier for the passage of ACE inhibitors into the vessel wall.     

Serostatus and counseling

Seroconcordance and serodiscordance are important issues in counseling for both HIV-positive and HIV-negative gay men. Just as gay psychotherapists have used self-disclosure as a tool to help clients feel understood, serostatus disclosure by therapists could also be beneficial. By serving as role models, counselors can help gay men remain uninfected and help men with AIDS take care of themselves. At the same time, counselors can aid both infected and affected men in maintaining a sense of hope and intimacy. Role modeling has been useful for many HIV-negative gay men, who often feel abandoned by communities and social services that focus on the needs of the HIV-positive community. As a result, mental health and social service providers have begun developing services, including support groups, particularly for HIV-negative gay men.     

Computed cranial tomographic findings in cerebral sinovenous occlusion.

Eleven patients with angiographically and/or pathologically verified cerebral sinovenous occlusions not directly caused by trauma were studied by computed cranial tomography (CCT). Static radionuclide brain scans and dynamic radionuclide flow studies were also obtained in four patients; in two, findings diagnostic of lateral sinus thrombosis were noted. These comprised a "negative on dynamic, hot on static" image, as well as a "hot on static with nonfilling on angiography." Computed cranial tomography findings included visualization of the thrombosed vein ("cord sign") or sinus ("empty triangle" or "delta sign"), multiple focal bilateral parasagittal hemorrhages, intense tentorial enhancement, gyral enhancement indistinguishable from infarct, solitary intracerebral hematoma, small ventricles, and normal scan. Excluding the patients with underlying meningioma, all three of whom survived, seven of the remaining eight patients expired during the acute phase of their illness, an 88% mortality. This group includes one patient who had normal CCT findings, albeit without contrast enhancement, who was diagnosed as pseudotumor cerebri. The need for full neuroradiological evaluation, including angiography, is thus stressed if this highly fatal yet treatable condition is not to remain undiagnosed.