Managing indigent care: a case study of a safety-net emergency department

OBJECTIVE: To examine how one safety-net emergency department (ED) managed problems associated with the provision of indigent care in everyday life. DATA SOURCES/STUDY SETTING: Interview and observational data collected in County Hospital ED, a public teaching hospital in a California city, during 6 months of 1999. STUDY DESIGN: The study used ethnographic methods to document and understand day-to-day routines and practices for providing indigent care in a safety-net facility. DATA COLLECTION/EXTRACTION METHODS: One- to 2-hour semistructured interviews with a snowball sample of eight ED physicians were tape recorded, and fieldnotes were recorded in situ during 10-30 hours of participant observation per week in all areas of the ED. Data were coded to highlight themes of interest and to identify recurrent patterns of behavior. PRINCIPAL FINDINGS: In everyday life, providers at County ED relied on graduate medical education (GME) to manage two everyday problems, social use and tenuous financing, associated with the provision of indigent care. GME helped manage problematic social visits to time ED by defining them as interesting cases. GME helped with tenuous finances by creating a work culture that encouraged the provision of uncompensated work. CONCLUSIONS: Safety-net facilities often face problems similar to those in County ED. Future research should assess the extent to which the everyday management of these problems in County ED resembles that in other safety-net facilities.     

Postvaccinal inflammatory neuropathy: peripheral nerve biopsy in 3 cases

Autoimmune inflammatory polyneuropathy (PN) can be triggered by vaccination. We report 3 such cases. A 36-year-old female nurse presented 15 days after a hepatitis B vaccination (HBV) with acute sensory disturbances in the lower limbs. She had severe ataxia but no weakness. Cerebrospinal fluid (CSF) protein level was 84 mg/100 mL, with 3 lymphocytes. A 66-year-old man presented 21 days after HBV with severe motor and sensory PN involving all 4 limbs. A 66-year-old man presented 15 days after a yellow fever vaccination with progressive motor and sensory PN involving all 4 limbs and bilateral facial paralysis. CSF protein level was 300 mg/100 mL, with 5 lymphocytes. Six weeks later, a tracheostomy was performed. In these 3 patients, the nerve deficits lasted for months. In each case, peripheral nerve biopsy showed KP1-positive histiocytes but no T-lymphocytes in the endoneurium. On ultrastructural examination, there was axonal degeneration in the first 2 cases; in case 2, a few myelinated fibers exhibited an intra-axonal macrophage but the myelin sheath was preserved. There was only 1 example of macrophage-associated demyelination in case 2, but these were numerous in case 3. It is likely that in the first 2 cases, an autoimmune reaction against some axonal or neuronal components was triggered by HBV. It induced an acute sensory ataxic PN in case 1 and an acute motor and sensory axonal neuropathy (AMSAN) in case 2. The third patient had a chronic inflammatory demyelinating PN, likely triggered by yellow fever vaccination.     

Assessment of personal protective equipment use among Midwestern farmers

BACKGROUND: Personal protective equipment (PPE) is readily available and widely recommended, yet usage among agricultural workers is largely unknown. METHODS: A mail survey of 2,483 farmers in six Midwestern states with telephone follow-up addressed PPE usage related to sun exposure, noise abatement, chain saw usage, welding and metal work, handling of large animals in and out of confinement facilities, feed handling, manure storage facilities, and mixing and applying chemicals. Summary statistics of survey responses were compiled. RESULTS: With the exception of welding masks, PPE usage was low. Farmers were satisfied with availability of PPE through local hardware and farm cooperatives, but the decision to use PPE was personal and influenced little by outside parties. CONCLUSION: PPE usage rates by farmers on Midwestern farms need to be increased. The desire of the individual farmer to reduce risk of personal injury or exposure should be targeted. The most effective venue will be local agricultural extension services.     

Role of work permits in teen workers' experiences

BACKGROUND: Work permits are required for working teenagers under 18 in 41 US states, but little is known about the work experience of those with work permits compared with those without such permits. This study examines job hazards, training, and knowledge of child labor laws reported by students in a predominantly Latino high school in Los Angeles and compares the responses of those who obtained work permits with those who did not. METHODS: Student responses to a 60 item questionnaire were supplemented with information from focus groups and a survey of work permits issued by the school. RESULTS: Students without work permits were more likely to perform hazardous tasks and to use certain types of dangerous equipment and less likely to receive health and safety training than those with permits. CONCLUSION: Possible explanations for the findings and suggested areas in need of policy change or research are considered.     

MR evaluation of coronary stents with navigator echo and breath-hold cine gradient-echo techniques

The aim of this study was to evaluate coronary artery stents with MR. Thirty-eight patients underwent MR imaging 48.1 +/- 6.6 days (range 38-60 days) after placement of 47 coronary stents of 11 different types, using navigator echo (NE) and cine gradient-echo (GE) techniques. For both sequences the low signal artifact was used to localize the stent, whereas the flow-related high signal before and distal to the stent was considered as a patency sign. Exercise electrocardiographic test (EET) had been performed 1-7 days before MR. No adverse event with possible relation to the MR examination was observed. All the stents were recognized as signal void with GE, and all but one with NE. Of the 2 patients with positive EET, the first one, with a stent on the left anterior descending coronary artery, presented low signal distal to the stent at both MR sequences, suggesting dysfunction [60% stenosis at conventional coronary angiography (CCA)]; the second one, with two sequential stents on the right coronary artery, presented lack of signal distal to the stents at both MR sequences, suggesting occlusion (97% stenosis at CCA). For the 44 remaining stents in 36 patients with negative EET, MR high signal before and distal to the stent suggested patency at both sequences. MR seems to be a safe and promising technique for non-invasive evaluation of coronary stents.     

热毒宁注射液治疗急性上呼吸道感染的临床研究

目的:评价热毒宁注射液治疗急性上呼吸道感染外感风热证的疗效和安全性。方法:71例急性上呼吸道感染病人随机分为2组,试验组给予热毒宁注射液治疗,20 ml.次.d-1,静脉滴注;对照组给予清开灵注射液治疗,1次.d-1,每次30 ml,静脉滴注。3 d为一个疗程。结果:治疗d 3试验组总体疗效优于对照组(98.08%,94.13%,P<0.01)。治疗d 3试验组中医证候疗效优于对照组(98.07%,94.11%,P<0.05)。未见明显的毒副作用和不良反应症状。结论:用药3 d后热毒宁注射液治疗急性上呼吸道感染外感风热证的疗效优于清开灵注射液,并且安全性良好。     

缬沙坦治疗轻中度高血压疗效和安全性的研究

目的评价缬沙坦治疗轻中度原发性高血压降压疗效和安全性。方法选择轻中度原发性高血压患者132例,采用随机、平行对照的方法,分成缬沙坦组(66例),每日1次80 mg口服;氨氯地平组(66例),每日1次5 mg口服。治疗4周末血压仍>140/90 mm Hg者剂量加倍。在8周观察期内不联用其他降压药。于治疗开始2、4、6、8周末测量诊室坐位谷值血压,同时记录性交次数、自觉症状及不良反应。实验开始前及结束时进行实验室检查。结果两组服药后2、4、6、8周收缩压和舒张压与服药前比较均有明显降低,差异有统计学意义(P<0.01);两组服药后2、4、6、8周血压下降对应组间比较差异无统计学意义(P>0.05);服药8周后,缬沙坦组和氨氯地平组血压达标率分别为89%和88%,组间比较差异无统计学意义。不良反应的发生率分别为缬沙坦组8%,氨氯地平组为6%,组间比较差异无统计学意义。两组试验结束时主要实验室检查指标,除缬沙坦组血钾与试验前比较差异有统计学意义外(P<0.05),其他差异均无统计学意义。缬沙坦组性功能均有不同程度的改善。结论缬沙坦对轻中度高血压患者疗效确切,安全可靠。     

司丙红霉素安全性药理学研究

目的:观察司丙红霉素对大鼠心血管、呼吸系统和小鼠中枢神经系统的影响。方法:健康SD大鼠分别按体重随机分为低、中、高3个剂量组和溶媒对照组。给药组分别从十二脂肠给予司丙红霉素75,150,300 mg·kg~(-1),对血压、心电图(ECG)、呼吸频率及呼吸幅度进行观察。小鼠实验分低、中、高3个剂量组及溶媒对照共4个组,分别灌胃给予司丙红霉素75,150,300 mg·kg~(-1),对动物一般活动和睡眠时间进行观察。结果:司丙红霉素300 mg·kg~(-1)剂量组使大鼠心率下降,对舒张压、收缩压、ECG之QRS时间、ST段、T波、QT间期、呼吸频率及呼吸幅度无明显的影响;对小鼠一般活动和睡眠时间无明显影响。75,150 mg·kg~(-1)剂量组对大鼠、小鼠各项指标无明显影响。结论:司丙红霉素300 mg·kg~(-1)对心血管系统有一定影响,可使大鼠心率下降。     

核酸疫苗的药动学与安全性研究进展

核酸疫苗是将编码某种抗原蛋白的外源基因（DNA或RNA）直接导入机体细胞内，通过宿主细胞的转录系统合成抗原蛋白，诱导宿主对该抗原蛋白的免疫应答，从而达到预防和治疗疾病的目的。作为一种新型疫苗，核酸疫苗迄今已有10余种被FDA批准进入非临床和临床试验，但其应用于人体的有效性、安全性、可接受性仍是值得关注的问题。基于对乙肝病毒DNA疫苗药动学的研究基础，结合近几年国内外相关研究，笔者对核酸疫苗的药动学与安全性进行综述。