Optimal allocation of resources over health care programmes: dealing with decreasing marginal utility and uncertainty

This paper addresses the problem of how to value health care programmes with different ratios of costs to effects, specifically when taking into account that these costs and effects are uncertain. First, the traditional framework of maximising health effects with a given health care budget is extended to a flexible budget using a value function over money and health effects. Second, uncertainty surrounding costs and effects is included in the model using expected utility. Other approaches to uncertainty that do not specify a utility function are discussed and it is argued that these also include implicit notions about risk attitude.     

Enhancing reflection: an interpersonal exercise in ethics education

There are no moral cookbooks--no algorithms for whipping up moral confections to suit every occasion. But more modest and flexible tools might still be useful for practical ethics. One team describes how professionals can be taught to use a framework for understanding moral problems.     

COPD: can prevention be improved? Proposal for an integrated intervention strategy

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a worldwide public health problem with increasing morbidity and mortality. The aim of this proposal is to contribute to the improvement of COPD prevention by identifying groups at risk for COPD and targeting them for preventive interventions. METHODS: Based on the existing organizational structures for COPD detection, detailed analysis of the determinants of COPD will allow to identify groups at high risk to develop COPD. The Stepwise Target Group-Oriented Prevention (STOP) model developed during this study proposes an integrated identification and intervention strategy for high-risk groups. RESULTS: Apart from smoking, other environmental determinants and host factors contribute to further lung function's rapid decline. Combined with smoking, these factors increase the risk for COPD. Target groups for early disease detection and appropriate interventions can be identified by the presence of one or more known risk factors and by identification of high-risk groups. CONCLUSION: The Stepwise Target Group-Oriented Prevention (STOP) strategy is a step toward improvement in COPD prevention, by shifting the focus from the group of a focus symptomatic smokers aged 45+ years to much earlier and preventable stages of the disease, that is, from disease treatment to risk management.     

Monitoring the size of the leprosy problem: which epidemiological indicators should we use?

The purpose of the study was to discuss the interpretation of epidemiological trends in leprosy, using currently available indicators. A number of leprosy-endemic countries and regions were chosen for which epidemiological data have been published for a period of at least 15 years. Using these examples, relative merit of the registered prevalence rate, the case detection rate, the children proportion among new cases and proportion of new cases with grade 2 disability will examined for interpreting the leprosy situation in these countries. Considerable drop of the registered prevalence rates (PR) were evident in all endemic countries. However, this decline was due largely to shortening of treatment and 'cleaning' of leprosy registers and has not been reflected in the annual case detection rates (CDR), except in a few countries. The proportion of new cases with grade 2 impairment had decreased substantially, which indicates earlier case finding. However, the proportion of children among new cases did not change much in the past decade. It is indicate that transmission is still continuing. We reiterate the conclusion of the ILA Technical Forum that the (annual) case detection rate is the most appropriate indicator for monitoring of leprosy situation in a given country or area. Two additional indicators that helped to interpret the CDR were the proportion of new cases with grade 2 impairments, reflecting the delay between occurrence and diagnosis of the disease, and the proportion of children among new cases, which is used as a proxy indicator for recent transmission.     

The NMDA-receptor antagonist MK-801 selectively disrupts reversal learning in rats

We tested the hypothesis that inhibition of NMDA-receptors in rats would lead to a selective impairment of reversal learning in a serial reversal task in the Skinner box. Low doses of MK-801 (0.025 and 0.05 mg/kg) did not affect acquisition of the two-lever discrimination, but impaired performance during the first reversal more than during the third reversal. Similar effects were observed during the series of extinction sessions. The high dose (0.1 mg/kg) completely inhibited reversal and extinction learning, as the rats perseverated in pressing the previously rewarded lever(s). We conclude that NMDA receptor blockade leads to a selective impairment in cognitive flexibility, and shows some similarity to transient inactivation of the medial prefrontal cortex in this respect.     

Clinical features in 130 patients with the velo-cardio-facial syndrome. The Leuven experience

The velo-cardio-facial syndrome (VCFS) is a leading cause of velopharyngeal dysfunction and cleft palate and caused by a submicroscopic deletion in the long arm of chromosome 22 (band 22q11). During the last 5 years, 130 patients with a 22q11 deletion were diagnosed in Leuven. Most patients presented a wide variety of the classical features of the velo-cardio-facial syndrome. Velopharyngeal dysfunction was almost always present whereas an isolated cleft lip/palate was observed in a minority of patients. The velopharyngeal function can be evaluated by the classic combination of indirect and direct techniques. Because of the frequent occurrence of the velo-cardio-facial syndrome, estimated at around 1/4000 live births, and given the extremely broad clinical spectrum which makes clinical diagnosis difficult, screening of patients with velopharyngeal dysfunction for a deletion 22q11 is indicated.     

Managing community and neighborhood partnerships in a community-based nursing curriculum.

A community-based undergraduate nursing program in a liberal arts college sought to establish partnerships with area neighborhoods to enhance the educational process of the program and the health of the neighborhoods. With the full financial and emotional support of the college administration, two unique positions were developed within the nursing department: community partnership coordinator (CPC) and neighborhood coordinator. The CPC works at the greater community level with involvement in area-wide community health ventures to provide a liaison to the community for the nursing department. The CPC coordinates area-wide student experiences, provides oversight to the community-based participatory research process, and expands scholarly opportunities for students and faculty. In addition, a neighborhood coordinator for each of the three underserved, ethnically diverse partnering neighborhoods provides an ongoing presence in the neighborhood, coordinating and teaching students as they have practicum experiences within the neighborhood. The neighborhood coordinator is also intimately involved in the neighborhood, maintaining professional relationships with neighborhood residents, leaders, agency representatives, and health care professionals. Discussion of how challenges of the roles were managed is included.     

The surgical management of chronic hypotony due to uveitis

PURPOSE: Evaluate surgery in chronic hypotony secondary to uveitis. METHOD: Retrospective analysis of six patients operated for chronic hypotony (< or =5 mmHg) of at least 1 month's duration. Surgery involved removal of all traction and membranes on the ciliary processes. Use of oil was limited to patients with atrophic ciliary processes. RESULTS: The average postoperative follow-up was 24 months (12-43). The average pressure increase was 7 mmHg at 6 months. Four of six uveitis patients had significantly increased vision. CONCLUSION: Improved vision, and a sustained pressure rise are possible in hypotonous uveitis. The presence of ciliary processes is necessary. However, they do not need to be intact.