Public and private prenatal care providers in urban Mexico: how does their quality compare?

OBJECTIVE: To evaluate variations in prenatal care quality by public and private clinical settings and by household wealth. DESIGN: The study uses 2003 data detailing retrospective reports of 12 prenatal care procedures received that correspond to clinical guidelines. The 12 procedures are summed up, and prenatal care quality is described as the average procedures received by clinical setting, provider qualifications, and household wealth. SETTING: Low-income communities in 17 states in urban Mexico. PARTICIPANTS: A total of 1253 women of reproductive age who received prenatal care within 1 year of the survey. MAIN OUTCOME MEASURE: The mean of the 12 prenatal care procedures received, reported as unadjusted and adjusted for individual, household, and community characteristics. RESULTS: Women received significantly more procedures in public clinical settings [80.7, 95% confidence interval (CI) = 79.3-82.1; P < or = 0.05] compared with private (60.2, 95% CI = 57.8-62.7; P < or = 0.05). Within private clinical settings, an increase in household wealth is associated with an increase in procedures received. Care from medical doctors is associated with significantly more procedures (78.8, 95% CI = 77.5-80.1; P < or = 0.05) compared with non-medical doctors (50.3, 95% CI = 46.7-53.9; P < or = 0.05). These differences are independent of individual, household, and community characteristics that affect health-seeking behavior. CONCLUSIONS: Significant differences in prenatal care quality exist across clinical settings, provider qualifications, and household wealth in urban Mexico. Strategies to improve quality include quality reporting, training, accreditation, regulation, and franchising.     

The morbidity and mortality conference: the delicate nature of learning from error.

The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.     

The pattern evoked response in disorders of the optic nerve

The pattern evoked electroretinogram (PERG) was investigated in 11 patients with unilateral optic nerve disease and in a series of age-matched controls. The visually evoked potential (VEP) was also measured. The PERG showed a similar reduction to the VEP in optic nerve disease. Serial studies indicate that the PERG may not be affected immediately in some instances but may show a gradual decline over several months.     

The pharmacokinetics of gamma-glutamyl-L-dopa in normal and anephric rats and rats with glycerol-induced acute renal failure.

1. The pharmacokinetics of gamma-glutamyl-L-dopa (gludopa) and its metabolite, L-dopa, have been studied in normal rats at three dose levels of gludopa: 2 mg kg-1, 5 mg kg-1 and 7.5 mg kg-1. The extent of metabolism in normal rats, and the pharmacokinetics in anephric rats and rats with glycerol-induced acute renal failure (ARF) were also studied at a gludopa dose of 2 mg kg-1. 2. Gludopa was extensively metabolised to L-dopa with only about 10% of an injected dose being excreted unchanged. Normal rats had a rapid gludopa clearance of 50.9 +/- 9.6 ml min-1 kg-1 and elimination rate constant of 2.99 +/- 0.27 h-1. The mean residence time and half-life were 20.9 +/- 1.4 and 14.4 +/- 1.0 min, respectively. The apparent volume of distribution at steady state was 1.05 +/- 0.18 l kg-1. 3. No statistically significant differences were found in the main pharmacokinetic parameters between ARF and controls for either gludopa or its metabolite L-dopa. 4. In anephric rats and controls the kidneys were found to contribute about 68.5% and 67.2% to the elimination of gludopa and the metabolite L-dopa, respectively. 5. These results confirm that gludopa is an efficient pro-drug for L-dopa, and that the kidneys are the major site of gludopa metabolism. It seems likely that the renal specificity of gludopa persists in ARF.     

Respiratory health status in swine producers using respiratory protective devices

A cross-sectional survey on respiratory health in swine producers showed that 30% of 301 examined men usually used a dust mask when working inside a barn. They did not differ significantly from dust mask nonusers in respect to respiratory symptoms and lung function. This analysis was undertaken to determine whether the respiratory health of dust mask users was associated with reasons why they had started individual respiratory protection. The subjects were recontacted in order to identify those who started using a mask to deliberately prevent symptoms (42 men) and those who started protection because of pre-existing respiratory symptoms (44 men). Not unexpectedly, betweengroup comparisons of respiratory symptoms and lung function suggest that swine producers who wear dust masks for preventive purposes have better respiratory health than those who wear dust masks because of symptoms or those who do not use individual respiratory protection. The individual reasons for starting dust mask usage should be examined among potential determinants of the outcomes of prospective studies which can then provide more valid assessment of the effect of individual respiratory protection. © 1993 Wiley-Liss, Inc.