European hospital reforms in times of crisis: Aligning cost containment needs with plans for structural redesign?

Hospitals have become a focal point for health care reform strategies in many European countries during the current financial crisis. It has been called for both, short-term reforms to reduce costs and long-term changes to improve the performance in the long run. On the basis of a literature and document analysis this study analyses how EU member states align short-term and long-term pressures for hospital reforms in times of the financial crisis and assesses the EU's influence on the national reform agenda. The results reveal that there has been an emphasis on cost containment measures rather than embarking on structural redesign of the hospital sector and its position within the broader health care system. The EU influences hospital reform efforts through its enhanced economic framework governance which determines key aspects of the financial context for hospitals in some countries. In addition, the EU health policy agenda which increasingly addresses health system questions stimulates the process of structural hospital reforms by knowledge generation, policy advice and financial incentives. We conclude that successful reforms in such a period would arguably need to address both the organisational and financing sides to hospital care. Moreover, critical to structural reform is a widely held acknowledgement of shortfalls in the current system and belief that new models of hospital care can deliver solutions to overcome these deficits. Advancing the structural redesign of the hospital sector while pressured to contain cost in the short-term is not an easy task and only slowly emerging in Europe.     

The HelpED Study: Agreement and Impact of the Erection Hardness Score on Sexual Function and Psychosocial Outcomes in Men with Erectile Dysfunction and Their Partners

IntroductionThe HelpED study assessed men with erectile dysfunction (ED) treated with a phosphodiesterase type 5 (PDE5) inhibitor and their female partner in a community setting.AimTo examine agreement in Erection Hardness Score (EHS) in patients and partners; to assess impact of EHS changes on other sexual health outcomes and behaviors.MethodsAt baseline and follow‐up 2 to 4 months later, men in a stable heterosexual relationship who had newly diagnosed or untreated ED (≥6 months) completed the single‐item EHS, the International Index of Erectile Function questions 4 and 5 (assessing erection maintenance), the Self‐Esteem And Relationship (SEAR) questionnaire, and a modified Quality of Life domain of the Sexual Life Quality Questionnaire (mSLQQ‐QOL). Partners completed the EHS, Female Sexual Function Index, and the mSLQQ‐QOL.Main Outcome MeasuresEHS agreement assessed by Cohen weighted kappa coefficient, associations between change in EHS and change in measures of sexual function and quality of life; outcomes stratified by patient age (≤55 years vs. >55 years).ResultsQuestionnaires were completed by 447 men (64% aged 51–70 years) and 253 partners (52% aged 46–60 years) at baseline and by 266 and 152, respectively, at follow‐up. At baseline, the consulting physician proposed PDE5 inhibitor treatment for 99% of patients, and EHS mean values were similar in patients and partners. All outcomes improved significantly (P < 0.05), including EHS in 75% of men (EHS3 [hardness sufficient for sexual intercourse but not fully hard] improved to EHS4 [fully hard erection] in almost 60%). For most other outcomes, improvement was greater in younger men and in those who improved from EHS3 to EHS4.ConclusionsStrong agreement in EHS between patient and partner and associations between improvement in EHS and improvements in measures of sexual function and quality of life in patients and partners support its clinical use in ED management. Claes HIM, Andrianne R, Opsomer R, Albert A, Patel S, and Commers K. The HelpED Study: Agreement and impact of the erection hardness score on sexual function and psychosocial outcomes in men with erectile dysfunction and their partners.     

Pulmonary hyaline membrane disease occurring in the course of VM-26 therapy

During treatment with VM-26 a 20-year-old patient with metastatic medulloblastoma developed an acute, fulminating pulmonary illness. Open lung biopsy revealed advanced alveolar hyaline membrane formation with interstitial round cell infiltrate. This is the first reported case of podophyllotoxin-related pulmonary disease.     

4-Caffeoyl-1,5-quinide in roasted coffee inhibits [<Superscript>3</Superscript>H]naloxone binding and reverses anti-nociceptive effects of morphine in mice

Rationale Cinnamoylquinides are formed from the corresponding chlorogenic acids during coffee roasting. Instant coffee has been shown to displace binding of the mu opioid receptor antagonist, [³H]naloxone, but the putative active agent, feruloylquinide, has not been characterized.Objectives The goal was to identify the active agent(s) in coffee by measuring the binding affinity of individual cinnamoyl-1,5-quinides to the human mu opioid receptor, and determine the effects of these compounds on morphine-induced anti-nociceptive behavior in mice.Methods Cinnamoyl-1,5-quinides in extracts of decaffeinated instant coffee were quantified by reverse-phase HPLC comparisons with synthetic samples of 3-coumaroyl-1,5-quinide and 4-coumaroyl-1,5-quinide, 3-caffeoyl-1,5-quinide and 4-caffeoyl-1,5-quinide (4-CQL) 3-feruloyl-1,5-quinide and 4-feruloyl-1,5-quinides and 3,4-dicaffeoyl-1,5-quinide (DICAQ). Affinities of the cinnamoyl-1,5-quinides and decaffeinated instant coffee extract were determined by displacement of [³H]naloxone binding in cultured HEK-MOR cells. Inhibition of the anti-nociceptive activity of morphine (1 mg/kg IP) was determined in C57BL/6J mice using the hot plate test at 52°C.Results Extract of decaffeinated instant coffee produced a displacement K_i of 42±16 mg/l, while the K_i of a synthetic sample of 4-CQL was 4.4±0.4 M. Compounds with a cinnamoyl substituent in the 4-position of the quinide, i.e. 4-CQL, DICAQ, 3,4-diferuloyl-1,5-quinide, and 3,4-dicoumaroyl-1,5-quinide, had affinities for the mu opioid receptor in the low micromolar range. In the hot plate test, coffee extract, containing 0.78% of 4-CQL, reversed the anti-nociceptive effect of morphine at 10 mg/kg IP. Two cinnamoyl-1,5-quinides found in roasted coffee, DICAQ, and 4-CQL, were active at 1 and 0.1 mg/kg IP, respectively.Conclusions These results suggest that the previously reported anti-opioid activity of instant coffee is caused primarily by the presence of 4-CQL, and to lesser extent by other cinnamoyl-1,5-quinides.     

Unresolved legal questions in cross-border health care in Europe: liability and data protection

Objectives

Directive 2011/24/EU was designed to clarify the rights of EU citizens in evaluating, accessing and obtaining reimbursement for cross-border care. Based on three regional case studies, the authors attempted to assess the added value of the Directive in helping clarify issues in to two key areas that have been identified as barriers to cross-border care: liability and data protection.

Study design

Qualitative case study employing secondary data sources including research of jurisprudence, that set up a Legal framework as a base to investigate liability and data protection in the context of cross-border projects.

Methods

By means of three case studies that have tackled liability and data protection hurdles in cross-border care implementation, this article attempts to provide insight into legal certainty and uncertainty regarding cross-border care in Europe.

Results

The case studies reveal that the Directive has not resolved core uncertainties related to liability and data protection issues within cross-border health care. Some issues related to the practice of cross-border health care in Europe have been further clarified by the Directive and some direction has been given to possible solutions for issues connected to liability and data protection.

Conclusions

Directive 2011/24/EU is clearly a transposition of existing regulations on data protection and ECJ case law, plus a set of additional, mostly, voluntary rules that might enhance regional border cooperation. Therefore, as shown in the case studies, a practical and case by case approach is still necessary in designing and providing cross-border care.     

Fatal pulmonary hypertension and resolving immune-complex glomerulonephritis in mixed connective tissue disease: A case report and review of the literature

Mixed connective tissue disease (MCTD) has been characterized as a benign rheumatic syndrome with a favorable response to immunosuppressive therapy. Serious renal and pulmonary involvement are reported to be rare in MCTD. We are describing a female adolescent with MCTD in whom fatal cor pulmonale developed due to recurrent thromboembolic primary pulmonary hypertension. Death occurred after two years of therapy with prednisone and azathioprine for an immune-complex glomerulonephritis. Paramesangial and intramembranous electron-dense deposits had been identified in several glomeruli at the start of treatment. Improved renal function and apparent histologic improvement were demonstrated four months after the institution of prednisone and azathioprine therapy, and stable renal function was maintained until death. The pulmonary hypertension was progressive and apparently not altered by either the prednisone or azathioprine. At necropsy, there was no evidence of a pulmonary arteritis or vascular immune-complex deposition to account for the recurrent thromboembolic lesions in the small pulmonary arteries and arterioles. This is a clinical course not previously described in patients with MCTD and may represent an extreme of the clinical spectrum of this syndrome.     

Multiple myeloma associated with immune thrombocytopenic purpura

Thrombocytopenia in patients with multiple myeloma is usually due to chemotherapy or marrow replacement with myeloma cells. Two patients with multiple myeloma who fulfilled criteria for the diagnosis of immune thrombocytopenic purpura are presented. The etiologic and therapeutic implications of this unusual association are discussed.     

How to change environmental conditions for health

Since the Lalonde report, contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. They are also important for public-health because environments are the complex systems through which people are both empowered and exercise their empowerment. If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific environmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article first presents one such analytical instrument. Then, building on examples relating to socio-economic health inequities, the analytical instrument is applied to reveal how it can add value to health professionals' effectiveness in planning interventions for more health-promoting environments.     

Representations of preconditions for and determinants of health in the Dutch press

As a mass medium which provides information to the public aboutboth the determinants of health and the conditioning of thosedeterminants through professional or civic means, the pressis an important object of study for health promoters, who regularlyseek to build upon and influence public understandings regardingthe etiology of health. This article investigates whether thefactors which the Dutch press portray as determining or allowingfor health are congruent with the central tenets of health promotionas these are detailed in the WHO's 1986 Ottawa Charter for HealthPromotion and 1997 Jakarta Declaration. A content analysis wasconducted on 600 randomly selected health-related articles appearingin the five Dutch newspapers with the largest average dailycirculation over 8 weeks. Two coders ascribed values to eachof the 600 articles for seven content variables, including determinanttheme of article, authority identifying determinant theme, meansand agent of determinant conditioning, breadth of populationaffected, and mediating populational attributes. Two form variables,text and graphic area, were also assessed by the coders. Findingsindicate that though there are some reasons to be encouraged,representations of the determinants of health in the Dutch pressare largely incompatible with the etiological assumptions ofhealth promotion. Health promoters, it is asserted, must continueto engage the press in order to take advantage of opportunitiesand gaps in health etiological coverage.