Effects of decentralisation and health system reform on health workforce and quality‐of‐care in Indonesia, 1993–2007

The impact of decentralisation, socioeconomic changes and healthcare reforms in Indonesia on type and distribution of healthcare providers and quality‐of‐care has been unclear. We examined workforce trends for healthcare facilities from 1993 to 2007 using the Indonesian Family Life Surveys. Each included a sample of public and private healthcare facilities, used standardised interviews for numbers and composition of staffing, and quality‐of‐care vignettes. There was an increase in multiprovider facilities and shift in profile of solo providers—increasing proportions of midwives and drop in doctors in rural areas (including facilities with doctors) and nurses in urban areas. Quality‐of‐care scores were low, particularly for nurses as solo providers. Despite increased numbers of healthcare workers and growth of the private sector, outer Java‐Bali and rural areas continued to be disadvantaged in workforce capacity and quality‐of‐care. The results have implications for accreditation and in‐service training requirements, the legal status of nurses and private sector regulation. Copyright © 2014 John Wiley & Sons, Ltd.     

Hepatitis C Management Simplification From Test to Cure: A Framework for Primary Care Providers

This article proposes a strategy for primary care providers to begin treating patients with hepatitis C virus (HCV). We are motivated by the need to expand HCV treatment and by developments that have simplified treatment for most patients. This article presents 5 steps to achieving quality HCV treatment in the primary care setting: (1) accurate diagnosis via reflex testing; (2) risk stratification and identifying comorbidities via pretreatment evaluation; (3) simple, once-daily, pan-genotypic HCV treatment regimens; (4) minimized on-treatment monitoring: and (5) posttreatment monitoring and high-quality care for comorbidities such as cirrhosis and injection drug use. We provide indications for referral to specialists: notably children, patients with genotype 3 and cirrhosis, advanced liver or kidney disease, previous treatment failures, drug interactions with recommended regimens, and hepatitis B co-infection. Finally, potential barriers for providers are discussed, as well as further research findings and policy interventions that can promote HCV treatment in the primary care setting. We believe that a substantial portion of patients with HCV can be treated safely and effectively by nonspecialists and that the engagement of primary care providers is critical to efforts to end the HCV epidemic.     

Characterization of human blood group scFv antibodies derived from a V gene phage-display library

Summary. We previously reported the initial characterization of five human single-chain Fv (scFv) antibody fragments specific for the blood group antigens B, D(Rh), E(Rh), Kp^b and HI. The scFvs were isolated from a phageantibody library constructed from the variable region genes of two non-immunized donors. In this paper we report the specificity, affinity and kinetics of antigen binding of these scFv fragments. All five scFvs agglutinated the appropriate red cell phenotype following the addition of a monoclonal antibody which recognizes a peptide tag incorporated into the scFv. The anti-B and anti-HI scFv molecules, which recognize high density carbohydrate antigens, spontaneously polymerized and agglutinated red cells directly. None of the antibody fragments showed cross-reactivity with other red cell antigens, with the exception of the anti-E which reacted weakly with E-negative cells. Specific scFv binding was confirmed by ELISA, flow cytometry and radioactive labelling. The anti-D scFv recognized 17 600 sites on cDE/cDE red cells with an association constant (K_a), of 5.2 × 10⁷ m ¹ and a rate constant for dissociation (k_off) of 1.9 × 10² s^-1. The anti-E scFv recognized 29 800 and 39 800 sites on cDE/cDE red cells in two experiments with K_as of 8.4 × 10⁶ and 4.4 × 10⁷ m ^-1. The k_off for this antibody was 2.7 × 10^-2s^-1. The results demonstrate that scFv antibody fragments specific for cell surface antigens and possessing affnities typical of the primary immune response can be obtained from a phage-display library.     

Potassium restoration in hypertensive patients made hypokalemic by hydrochlorothiazide

Among 447 hypertensive patients, most with a history of diuretic-induced hypokalemia, 252 developed diuretic-induced hypokalemia while receiving hydrochlorothiazide, 50 mg/d. In a randomized study we evaluated the efficacy of three drug regimens in restoring potassium levels while maintaining blood pressure control: hydrochlorothiazide (50 mg/d) plus potassium supplement (20 mmol/d); hydrochlorothiazide (50 mg/d) plus potassium supplement (40 mmol/d); or hydrochlorothiazide (50 mg/d) with triamterene (75 mg/d) in one combination tablet. In all groups, mean serum levels of potassium rose within 1 week and showed no further change thereafter. However, the hydrochlorothiazide/triamterene and hydrochlorothiazide plus 40 mmol of potassium regimens were significantly more effective in restoring serum potassium levels than was the hydrochlorothiazide plus 20 mmol of potassium regimen. A significant increase in magnesium levels was observed only in the group treated with the hydrochlorothiazide/triamterene combination. Each regimen provided continued control of mild to moderate hypertension.     

Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract

BACKGROUND: Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics. METHODS: The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies. RESULTS: By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%. CONCLUSIONS: To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.     

Association of HLA-Dw16 with rheumatoid arthritis in Yakima Indians. Further evidence for the "shared epitope" hypothesis.

Rheumatoid arthritis (RA) is prevalent in Yakima Indians, a Native American tribe. HLA-DR4, the HLA specificity commonly associated with RA in Caucasians, is rare among the Yakima. Using a specific oligonucleotide probe that recognizes DR4 nucleotide sequences associated with RA, a rare HLA-Dw16 gene was identified in 83% of Yakima patients with RA and in 60% of Yakima control subjects. This shared sequence encodes a discrete class II epitope that is highly correlated with RA in both DR4 positive and DR4 negative individuals.