Benchmarking of performance of Mexican states with effective coverage

Benchmarking of the performance of states, provinces, or districts in a decentralised health system is important for fostering of accountability, monitoring of progress, identification of determinants of success and failure, and creation of a culture of evidence. The Mexican Ministry of Health has, since 2001, used a benchmarking approach based on the World Health Organization (WHO) concept of effective coverage of an intervention, which is defined as the proportion of potential health gain that could be delivered by the health system to that which is actually delivered. Using data collection systems, including state representative examination surveys, vital registration, and hospital discharge registries, we have monitored the delivery of 14 interventions for 2005-06. Overall effective coverage ranges from 54.0% in Chiapas, a poor state, to 65.1% in the Federal District. Effective coverage for maternal and child health interventions is substantially higher than that for interventions that target other health problems. Effective coverage for the lowest wealth quintile is 52% compared with 61% for the highest quintile. Effective coverage is closely related to public-health spending per head across states; this relation is stronger for interventions that are not related to maternal and child health than those for maternal and child health. Considerable variation also exists in effective coverage at similar amounts of spending. We discuss the implications of these issues for the further development of the Mexican health-information system. Benchmarking of performance by measuring effective coverage encourages decision-makers to focus on quality service provision, not only service availability. The effective coverage calculation is an important device for health-system stewardship. In adopting this approach, other countries should select interventions to be measured on the basis of the criteria of affordability, effect on population health, effect on health inequalities, and capacity to measure the effects of the intervention. The national institutions undertaking this benchmarking must have the mandate, skills, resources, and independence to succeed.     

Relación entre estrés y malestar psicológico de los padres y problemas emocionales y conductuales en niños preescolares con trastorno del espectro autista

IntroductionThe Autistic Spectrum Disorders (ASD) are characterised by general deficits in social communication, stereotypes, and restricted interests. The ASD have a high prevalence of additional psychiatric disorders that make their daily functioning worse, and reduces the quality of life of them and their families.Material and methodsIn an effort to identify family environmental characteristics that may influence in the course of additional psychiatric disorders, this study has focused on the symptoms of parental stress and psychological distress as possible risk factors. A cross-section study was carried out on the relationship between the stress and psychological distress of the parents and its relationship with co-existing psychopathology in a population of pre-school children with ASD (2-6 years).Results and conclusionsHigh levels of stress and psychological distress of the parents arealready associated, since early childhood, with co-existing psychiatric symptoms, specifically with emotional and behavioural problems (p < 0.05). However, further longitudinal studies are needed for a better understanding of the causal relationship between these variables and their possible bidirectional relationship.     

Is <Emphasis Type="Italic">Candida</Emphasis> colonization of central vascular catheters in non-candidemic,non-neutropenic patients an indication for antifungals?

Purpose  To assess the influence of antifungal therapy on the outcome of non-candidemic adult patients with central vascular catheter (CVC) tips colonized by Candida species. Methods  A retrospective analysis of the outcome of patients with Candida colonization of their CVC tip and no concurrent candidemia was made over a 4-year period. Patients who either died or developed candidemia-invasive candidiasis (poor outcome) were compared with those who improved. Results  We finally included 58 patients for analysis. Almost all (91.4%) had to be admitted to the ICU during their hospital stay. Independent predictors for outcome were a McCabe and Jackson score corresponding to ultimately fatal underlying disease [odds ratio (OR) 11.98; 95% confidence interval (CI), 1.37–104.97; P = 0.02], and maximum severity corresponding to severe sepsis, septic shock or multiorgan failure (OR: 6.16, CI 95%: 1.00–37.93; P = 0.05). We were unable to demonstrate that antifungal therapy was an independent variable influencing outcome (OR 0.82; 95% CI, 0.27–2.47; P = 0.73). Conclusions  Our data suggest that, in non-neutropenic critically ill patients with no concomitant candidemia and with CVC tips colonized by Candida, antifungal therapy does not seem to have a significant influence on clinical outcome. This article is discussed in the editorial available at: doi:.     

Validation of a multicenter computer-based surveillance system for hospital-acquired bloodstream infections in neonatal intensive care departments

Automated systems can facilitate surveillance for health care-associated infections. The New York Antimicrobial Resistance Project (NYARP) electronically monitors trends in bloodstream infections from 6 medical centers in New York, NY. To validate NYARP's data, episodes of health care-associated bloodstream infections detected by this system were compared with those obtained by an infection control practitioner performing an unrelated study in 2 participating neonatal intensive care departments. The sensitivity (84%), specificity (99%), and positive (84%) and negative (99%) predictive values of NYARP were excellent when coagulase-negative staphylococcal bloodstream infections were removed.     

Doxazosin GITS versus standard doxazosin in mild to moderate hypertension

BACKGROUND: The selective alpha 1-adrenoceptor antagonist doxazosin in both standard formulation and gastrointestinal therapeutic system (GITS) controlled-release formulation is effective for hypertension without having a negative impact on serum lipids. This study was designed to compare the relative efficacy of these two formulations of doxazosin on clinic and ambulatory blood pressure and serum lipids in patients with mild to moderate hypertension. METHODS: Hypertensive patients aged 18-70 years (n = 335) were evaluated in a multi-center prospective randomized study. Following a 2-week placebo run-in phase, patients were randomized to receive doxazosin 2 or 4 mg, with dose titration, or doxazosin GITS 4 mg, no dose titration, for 9 weeks. RESULTS: Both doxazosin formulations reduced clinic diastolic and systolic blood pressure from baseline (P < 0.0001). Doxazosin GITS and doxazosin 4 mg had similar blood pressure-lowering effects. Doxazosin GITS reduced sitting diastolic and systolic blood pressure compared with doxazosin 2 mg (P < 0.01 for both). A greater proportion of the doxazosin GITS group reached goal blood pressure (< or = 140/90 mm Hg) after 9 weeks compared with the doxazosin 2-mg group. All doses of doxazosin reduced 24-h and daytime (7:00 am to 10:00 pm) ambulatory blood pressure from baseline (all P < 0.01). Doxazosin GITS significantly reduced nighttime (10:00 pm to 7:00 am) ambulatory blood pressure from baseline. A neutral effect on serum lipids was observed with doxazosin. CONCLUSIONS: Doxazosin GITS and doxazosin were effective in reducing clinic and ambulatory blood pressure. The GITS formulation reduced the need for dose titration. Both doxazosin formulations were well tolerated.     

Ischemia Modified Albumin for the assessment of patients presenting to the emergency department with acute chest pain but normal or non-diagnostic 12-lead electrocardiograms and negative cardiac troponin T

BACKGROUND: The diagnosis of myocardial ischemia in patients with acute chest pain at rest but non-diagnostic electrocardiograms (ECG) is problematic. Ischemia Modified Albumin (IMA) is a new biochemical marker of ischemia, which may be useful to characterise acute coronary syndrome (ACS) patients. METHODS: We studied 131 patients (mean age 58.5 years; 95 male) presenting to the emergency department with symptoms suggestive of ACS but with normal or non-diagnostic ECGs. Cardiac troponin T (cTnT) and IMA were measured within 3 h of last chest pain episode. Based on hospital diagnostic test results, patients were classified as having ACS or non-ischemic chest pain (NICP), by two independent cardiologists unaware of IMA results. RESULTS: Mean IMA levels (U/ml) were higher in patients with ACS (98.3+/-11) compared to patients with NICP (85.5+/-15); p<0.0001. IMA levels >93.5 U/ml demonstrated a sensitivity and specificity of 75% for the diagnosis of ACS; area under the receiver operator characteristic curve 0.78 (95% CI: 0.70-0.85). If we applied the manufacturer cutoff point of 85 U/ml, the sensitivity of IMA increased to 90.6% with a specificity of 49.3% (negative predictive value=84.6%). In combination with cTnT (6-12 h) (>0.05 ng/ml), the sensitivity increased to 92.2%. After multivariate analysis, IMA levels >85 U/ml (odds ratio=14.6 [95% CI 4.4-48.4]; p<0.0001), age and prior myocardial infarction were independent predictors of ACS. CONCLUSION: IMA may be a useful biomarker for the identification of ACS in patients presenting with typical acute chest pain but normal or non-diagnostic ECGs.     

Chemoattractant-induced phosphatidylinositol 3,4,5-trisphosphate accumulation is spatially amplified and adapts, independent of the actin cytoskeleton

Experiments in amoebae and neutrophils have shown that local accumulations of phosphatidylinositol 3,4,5-trisphosphate [PI(3,4,5)P(3)] mediate the ability of cells to migrate during gradient sensing. To define the nature of this response, we subjected Dictyostelium discoideum cells to measurable temporal and spatial chemotactic inputs and analyzed the accumulation of PI(3,4,5)P(3) on the membrane, as well as the recruitment of the enzymes phosphoinositide 3-kinase and PTEN. In latrunculin-treated cells, spatial gradients elicited a PI(3,4,5)P(3) response only on the front portion of the cell where the response increased more steeply than the gradient and did not depend on its absolute concentration. Phosphoinositide 3-kinase bound to the membrane only at the front, although it was less sharply localized than PI(3,4,5)P(3). Membrane-bound PTEN was highest at the rear and varied inversely with receptor occupancy. The localization of PI(3,4,5)P(3) was enhanced further in untreated polarized cells containing an intact cytoskeleton. Interestingly, the treated cells could respond to two independent gradients simultaneously, demonstrating that a response at the front does not necessarily inhibit the back. Combinations of temporal and spatial stimuli provided evidence of an inhibitory process and showed that a gradient generates a persistent steady-state response independent of a previous history of exposure to chemoattractant. These results support a local excitation/global inhibition model and argue against other schemes proposed to explain directional sensing.     

Basolateral ClC-2 chloride channels in surface colon epithelium: regulation by a direct effect of intracellular chloride

BACKGROUND & AIMS: The principal function of the colon in fluid homeostasis is the absorption of NaCl and water. Apical membrane Na(+) channels, Na(+)/H(+), and Cl(-)/HCO(3)(-) exchangers have been postulated to mediate NaCl entry into colonocytes. The basolateral exit pathway for Cl(-) has recently been proposed to be via ClC-2 channels present in that membrane domain in surface epithelium. The aim of this report is to obtain functional data for a basolateral localization of ClC-2 and explore a possible direct regulation by intracellular Cl(-). METHODS: Guinea pig colon epithelium with the apical membrane perforated with nystatin in Ussing chambers is used to show a basolateral Cl(-) conductance. Gramicidin D perforated-patch configuration of the patch-clamp technique is used on isolated surface colonocytes. Heterologous expression of the recombinant channel and the whole-cell configuration are used to investigate a direct regulation by intracellular Cl(-). RESULTS: A basolateral membrane conductance with the characteristics of ClC-2 channels, including Cd(2+) sensitivity, selectivity, and inhibition by extracellular alkalinization, is present in distal colon epithelium. The effect of intracellular Cl(-) on this conductance suggests activation by the permeant anion. Using the recombinant ClC-2 channel, a strong dependence of its activity on intracellular Cl(-) is shown, with a shift of activation to more positive voltages as [Cl(-)](i) is increased. CONCLUSIONS: It is suggested that ClC-2 serves as an exit pathway for Cl(-) in the basolateral membranes of the distal colon and that its dependence on [Cl(-)](i) might provide a cross-talk mechanism to match fluxes at the apical and basolateral domains of these epithelial cells.     

Digoxin use is associated with increased platelet and endothelial cell activation in patients with nonvalvular atrial fibrillation.

OBJECTIVES: The purpose of this study was to determine whether digoxin use is associated with increased flow cytometric markers of endothelial cell and platelet activation in patients with nonvalvular atrial fibrillation (AF). BACKGROUND: Increased intracellular calcium is a key event in platelet activation, and several studies have demonstrated that digitalis activates platelets in vitro. Intracellular calcium also is a key regulator of endothelial cell function, and endogenous digitalis-like substances have been shown to affect biologic processes in endothelial cells. METHODS: We studied 30 patients with nonvalvular AF. We measured the levels of (1) platelet expression of P-selectin (CD62P), (2) platelet microparticles (PMP); and (3) endothelial microparticles (EMP) identified by anti-CD31 (EMP31) and by anti-E-selectin antibodies (EMP62E). RESULTS: Patients who were taking digoxin (n = 16; mean digoxin level = 0.93 ng/dL) did not demonstrate any significant differences in clinical or echocardiographic characteristics compared with patients not taking digoxin (n = 14). Patients taking digoxin had significantly increased levels of CD62P expression in platelets and platelet-leukocyte conjugates and markedly increased markers of endothelial activation: EMP62E and EMP31. After adjusting for potential confounders (including age, congestive heart failure, coronary artery disease, ejection fraction, antiplatelet, beta-blocker, and calcium channel blocker use), the differences persisted. CONCLUSIONS: Digoxin use in patients with AF is associated with increased levels of endothelial and platelet activation. If digitalis activates endothelial cells and platelets at pharmacologic doses, use of digitalis in conditions such as AF could predispose to thrombosis and vascular events.