Legitimate decision making: the Achilles' heel of solidaristic health care systems

The future sustainability of 'solidaristic' or universal publicly financed health systems is frequently said to be threatened by lack of resources as rising demand collides with the growing reluctance of the better-off to pay for services mainly used by others. Competitive health care arrangements are also regarded as threatening solidarity. By contrast, I argue that the main threat to the sustainability of such systems lies in the inability of so-called 'advanced' societies to develop institutions that are capable of acceptably reconciling inevitably scarce resources with individual and collective desires to have all the health care we want. Many 'advanced' societies lack, or fail to incorporate into their health systems, the range of intermediate institutions that could potentially help in more effectively reconciling individual wants with collectively determined levels of resources.     

Prediction of Caesarean Section from Ultrasound and Clinical Assessment of Fetal Size

EDITORIAL COMMENT: We accepted this paper for publication because the authors have explored the possible value of ultrasound versus clinical assessment of fetal size to see whether they can predict the need for Caesarean section when the baby is large. In this study both the ultrasound and the clinical assessment were impressively accurate and fetal femur length was the most accurate of the ultrasound parameters in assessing fetal weight in predicting the need for Caesarean section. However, as the authors indicate, none of these methods of assessment of fetal size are recommended as an absolute indication for Caesarean section. Every obstetrician uses clinical assessment of the fetus when evaluating management of the patient but the need for clinical judgment remains.
Summary: One hundred and five women with singleton pregnancies and cephalic presentation were assessed. Fundal height and a clinical estimate of fetal weight were recorded. The fetal biparietal diameter, abdominal circumference and femur length were measured with ultrasound. Ultrasound estimated fetal weight was calculated using 3 different formulas (Shepard, Campbell and CUHK). The liquor volume was assessed using the amniotic fluid index.
Ultrasound was able to predict Caesarean section with more reliability than clinical assessment of fetal size or weight. The biparietal diameter, fundal height and amniotic fluid index were poor predictors of mode of delivery. The measurements which best predicted the mode of delivery were the fetal femur length and abdominal circumference. Femur length, but not abdominal circumference, was a statistically better predictor of Caesarean section than clinical estimation of fetal weight. There was no improvement in prediction using ultrasound estimated fetal weight.     

PROLONGED PREGNANCY AND THE BIOPHYSICAL PROFILE A Birthing Center Perspective

A triage system for antepartum surveillance of postdates pregnancy is studied in a busy, indigent care service with limited resources for in-hospital delivery. One hundred seventy-eight pregnancies (13.2% of the total population) were thought to be at least 42 weeks' gestation by clinical criteria, and 128 of these underwent at least one complete biophysical profile within seven days of delivery. We find no statistically significant difference in the incidence of meconium staining, fetal distress in labor, or low Apgar scores when either the high or low scoring groups are compared, or when compared with the 50 patients who delivered without a biophysical evaluation. Specific components of the testing schema, however, namely oligohydramnios and spontaneous decelerations on the nonstress test, are highly associated with adverse perinatal events. Of the total population thought to be postmature clinically, only 60 infants (33.9%) were actually beyond 42 weeks' gestation by Dubowitz scoring. We conclude that a modified biophysical assessment as described is easily performed in a nontertiary care setting where a CNM-MD team approach is applied and may help to differentiate patients who require expeditious termination of pregnancy in-hospital from those who can be managed expectantly in the birthing center.     

Hepatic leiomyomas in two adult patients with AIDS: intravenous contrast-enhanced CT and MR imaging

Multiple opportunistic infections and neoplasms have been described in the AIDS population over the past 20 years. Four cases of AIDS-related hepatic smooth muscle tumors (leiomyomas) have been described, and of these, three were in children. The fourth case was in a single patient with two hepatic lesions. We describe the imaging features of two adult cases with biopsy-proven hepatic leiomyomas. In one of the cases, the gadolinium-enhanced MRI findings are described, which have not previously been reported. Electronic Publication     

Quality of pharmacotherapy consultations provided by drug information centers in the United States

We evaluated the performance of 116 U.S. drug information centers in responding to specific questions about drugs. The primary measures were correctness of responses and extent of probing for patient data. Questions addressed the effect of ranitidine on blood alcohol concentrations, the potential interaction between didanosine and dapsone, prevention of nonsteroidal antiinflammatory drug (NSAID)-induced peptic ulcers, and use of erythromycin for diabetic gastroparesis. The percentages of centers providing correct overall responses were 70% for the ranitidine question, 90% for the didanosine-dapsone question, 8% for the NSAID question, and 20% for the erythromycin question. For the three patient-specific questions, the percentages of centers eliciting vital patient data were 27% for the didanosine-dapsone question, 86% for the NSAID question, and 5% for the erythromycin question. In providing pharmacotherapy consultations, drug information centers generally failed to obtain pertinent patient data, thereby risking incorrect responses and inappropriate recommendations.     

Identifying dimensions of performance in local public health systems: results from the National Public Health Performance Standards Program.

This article uses data from the National Public Health Performance Standards Program to explore how the performance of essential public health services varies across communities and to identify underlying domains of activity that appear to drive variation in performance. Cross-sectional data were used from 315 local public health jurisdictions located within seven states that participated in the Performance Standards Program pilot tests between 1999 and 2001. Results demonstrate that local public health systems vary considerably in the extent to which they perform essential services and meet established performance standards. Factor analysis results indicate that four underlying domains of activity explain much of the variation observed in the individual performance measures, and that achieving performance standards for a single essential public health service often involves more than one underlying domain of activity. The findings suggest that composite measures constructed from the Performance Standards Program can assist public health decision makers in monitoring the performance of public health systems and identifying promising pathways for improving performance.     

Spectrophotometric determination of cephapirin, a cephalosporin antibacterial.

A simple and specific method for the quantitative determination of cephapirin, a cephalosporin antibacterial, in finished bulk and dosage forms is reported. The method is based on reproducible degradation under controlled conditions to an unidentified species, which is measured spectrophotometrically at 375 nm. The procedure can be performed manually on a short series of samples in about 15 min or can be automated for large runs. Precursors and related substances show minimal interference. The coefficient of variation of the automated system is about 1% within days and 1.3% among days.