Physician workforce planning and the transition to primary health care in former socialist countries

With the collapse of the Soviet Union, countries in Eastern Europe and the Newly Independent States inherited a physician workforce that was often too large, dominated by specialists, and poorly prepared for the transition to primary health care and the addition of the family/general practice specialty. We examine attempts in selected countries to plan the future physician workforce, while attempting to reduce the size of the workforce and train physicians to lead the transition to primary health care (PHC). We look the impact these efforts have had on the current workforce and will have on the future physician workforce. With few exceptions, the first move after independence was to reduce the inputs into the physician workforce in an attempt to reduce the size of the workforce, considered large by western standards, in 1990 between 350 and 400 per 100, 000 population compared to the EU average of 299. These reductions often did not result from planning and ignored the lengthy physician training process, leading to concerns for the future supply of physicians and the conclusion that many other factors were influencing the number of physicians. At the same time, two methods were being employed to rapidly prepare physicians for PHC, retraining of existing physicians for the short-term and the establishment of training programs in the faculties of medicine to train family/general practitioners (GPs) for the long-term. GPs per 100,000 population remained at about 102 throughout the period in the original EU countries, but in the new EU countries went from 51 in 1991 to 63 in 2002. The success of the programs was varied and often depended on the overall organization of the physician workforce, the status of the new family physician within the workforce and the commitment at the national level to the transition to PHC. After over a decade of independence, there is still a struggle to have a physician workforce with the right numbers, the right specialty mix, and practicing in the right locations.     

S-nitrosothiol-induced rapid cytochrome c release, caspase activation and mitochondrial permeability transition in perfused heart

Nitric oxide (NO) is a physiological signalling molecule, however, at high concentrations NO is cytotoxic, and has been implicated in a wide range of inflammatory, ischaemic and degenerative diseases, including heart failure. We investigated whether NO or S-nitrosothiols can induce apoptosis in perfused heart, and whether it is mediated via the mitochondrial pathway of caspase activation. We found that perfusion of rat hearts with a physiological S-nitrosothiol, S-nitrosoglutathione, at 0.4-1mM concentrations for just 10 min caused the release of cytochrome c from mitochondria into the cytosol, inhibition of mitochondrial respiration and caspase activation. Inhibited mitochondrial respiration was restored when exogenous cytochrome c was added to mitochondria, indicating that respiratory inhibition was caused by lack of cytochrome c in mitochondria. Release of cytochrome c, respiratory inhibition and caspase activation were prevented when hearts were pre-perfused with cyclosporin A, suggesting that mitochondrial permeability transition pore was involved. In contrast, perfusion of the hearts with diethylenetriamine/NO adduct releasing similar levels of NO to the S-nitrosoglutathione had no measurable effect on the heart. These data suggest that S-nitrosothiols are potent inducers of apoptosis in the heart and that S-nitrosothiol-induced apoptosis is mediated by mitochondrial permeability transition but not via NO.     

The effectiveness of caloric value of enteral nutrition in patients with major burns

Enteral nutrition as an important component of modern treatment is mandatory for patients suffering from major burns. Regardless of the initial estimation of caloric requirements, actual daily volume of energy consumption may vary depending on the general condition of the patient and the side effects of enteral nutrition. The aim of our study was to investigate the relation between caloric value of enteral nutrition and treatment course. METHODS: The prospective study involved 103 adult patients treated in the Hospital of Kaunas University of Medicine for 2 degrees -3 degrees burns of 10-80% body surface area from 1 January 2001 till 31 December 2003. All patients received enteral nutrition during the acute phase. After the completion of the treatment, caloric value of enteral nutrition was estimated, and patients were divided into two groups: group A received more than 30 kcal/(kg 24 h); and group B, received less than 30 kcal/(kg 24 h). We compared patients' mortality, complication rate, and hospital stay time. RESULTS: The mortality of patients, who enterally received less than 30 kcal/(kg 24 h), was 32.6%, comparing to 5.3% mortality in patients who received 30 or more kcal/(kg 24 h) (p < 0.01). The caloric value of less than 30 kcal/(kg 24 h) increased the frequency of pneumonia by 2.0 times, and the frequency of sepsis by 1.8 times (p < 0.05). The duration of the treatment of survivors in this group was by 12.6 days longer (p = 0.01). CONCLUSIONS: The caloric value of enteral nutrition seems to be associated with patient mortality, complication rate, and treatment duration. The results of the treatment of patients who received more or 30 kcal/(kg 24 h) were much better. Because determined relationship may not be directly causal, further study is needed to determine whether active intervention to improve nutrition could improve outcomes.     

Severity at onset of childhood type 1 diabetes in countries with high and low incidence of the condition

Severity of Type 1 diabetes mellitus (DM) at presentation was compared between south-east Sweden and Lithuania where incidence of childhood Type 1 diabetes is three times lower than in Sweden. New cases of diabetes at age 0-15 years from August 1995 to March 1999 in south-east Sweden and from August 1996 to August 2000 in Lithuania were included. Symptoms and clinical characteristics at diagnosis were recorded. Data about the close environment were collected using questionnaires. Lithuanian children were diagnosed in a more severe condition, mean pH 7.30 and HbA(1c) 11.5% compared with mean pH 7.36 and HbA(1c) 9.7% in Swedish children (P<0.0001). More Lithuanian than Swedish children were diagnosed in ketoacidosis (pH < or = 7.2, hyperglycaemia and ketonuria), 21.3 versus 7.3% (P<0.0001). Only 4.6% of Swedish children and 1.0% of Lithuanian children had no symptoms (P=0.007). Children in families with at least one first degree relative with diabetes (12.2% in Sweden and 8.4% in Lithuania, NS) had laboratory values at diagnosis closer to normal than sporadic cases in either country. Factors predicting ketoacidosis in Sweden were an unemployed mother and absence of infections in the 6 months before diagnosis. In Lithuania it was younger age and mother with less education. Additional educational activities for doctors are needed in countries with low incidence to reduce prevalence of ketoacidosis at onset.     

Different profiles of cytokine expression during mild and severe acute pancreatitis

AIM:To study secretion patterns of proand anti-in-flammatory cytokines, and activation of various cellular subsets of leukocytes in peripheral blood.METHODS: We have conducted a prospective obser-vational study. One hundred and eight patients with a diagnosis of acute pancreatitis and onset of the disease within last 72 h were included in this study. The mRNA expression of 25 different types of cytokines in white blood cells was determined by quantitative real time polymerase chain reaction. Levels of 8 dif...     

Higher prevalence of autoantibodies to insulin and GAD65 in Swedish compared to Lithuanian children with type 1 diabetes

We compared the prevalence of beta-cell autoantibodies and genetic risk factors in Sweden and Lithuania. Ninety-six patients from Sweden and 96 from Lithuania matched for age and gender (1-15 years old, median age 9.0 years) were included. We analyzed autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA) and the protein tyrosine phosphatase like IA-2 (IA-2A) as well as risk-associated polymorphisms of HLA, insulin and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) genes. The frequency of patients positive for IAA and GADA was higher in Sweden than in Lithuania (p = 0.043 and 0.032). The differences remained even when the patients were matched for HLA, insulin and CTLA-4 risk genotypes. Patients with low levels of IAA had higher levels of HbA1c and ketones at diagnosis. The frequency of the risk haplotype DR4-DQ8 was higher in Swedish than in Lithuanian patients (p = 0.004), as well as the high-risk combination of DR4-DQ8 and DR3-DQ2 haplotypes (p = 0.009). Our results suggest that autoimmune process against insulin and GAD(65) is more common at diagnosis in children in areas with high incidence of type 1 diabetes (T1D), independent of genetic risk markers. Furthermore, the disease in patients with insulin autoantibodies seems to be clinically milder.     

Early recognition of abdominal compartment syndrome in patients with acute pancreatitis

AIM： To assess the value of widely used clinical scores in the early identification of acute pancreatitis （AP） patients who are likely to suffer from intra-abdominal hypertension （IAH） and abdominal compartment syndrome （ACS）.
METHODS： Patients （η = 44） with AP recruited in this study were divided into two groups （ACS and non-ACS） according to intra-abdominal pressure （IAP） determined by indirect measurement using the transvesical route via Foley bladder catheter. On admission and at regular intervals, the severity of the AP and presence of organ dysfunction were assessed utilizing different multifactorial prognostic systems： Glasgow-Imrie score, Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE-Ⅱ） score, and Multiorgan Dysfunction Score （MODS）. The diagnostic performance of scores predicting ACS development, cut-off values and specificity and sensitivity were established using receiver operating characteristic （ROC） curve analysis.
RESULTS： The incidence of ACS in our study population was 19.35%. IAP at admission in the ACS group was 22.0 （18.5-25.0） mmHg and 9.25 （3.0-12.4） mmHg in the non-ACS group （P 〈 0.01）. Univariate statistical analysis revealed that patients in the ACS group had significantly higher multifactorial clinical scores （APACHE Ⅱ, Glasgow-Imrie and MODS） on admission and higher maximal scores during hospitalization （P 〈 0.01）. ROC curve analysis revealed that APACHE Ⅱ, Glasgow-Imrie, and MODS are valuable tools for early prediction of ACS with high sensitivity and specificity, and that cut-off values are similar to those used for stratification of patients with severe acute pancreatitis （SAP）.
CONCLUSION： IAH and ACS are rare findings in patients with mild AR Based on the results of our study we recommend measuring the IAP in cases when patients present with SAP （APACHE Ⅱ 〉 7; MODS 〉 2 or Glasgow-Imrie score 〉 3）.