Selection tools and student diversity in health professions education: a multi-site study

Student diversity in health professions education (HPE) can be affected by selection procedures. Little is known about how different selection tools impact student diversity across programs using different combinations of traditional and broadened selection criteria. The present multi-site study examined the chances in selection of subgroups of applicants to HPE undergraduate programs with distinctive selection procedures, and their performance on corresponding selection tools. Probability of selection of subgroups (based on gender, migration background, prior education, parental education) of applicants (N = 1935) to five selection procedures of corresponding Dutch HPE undergraduate programs was estimated using multilevel logistic regression. Multilevel linear regression was used to analyze performance on four tools: prior-education grade point average (pe-GPA), biomedical knowledge test, curriculum-sampling test, and curriculum vitae (CV). First-generation Western immigrants and applicants with a foreign education background were significantly less likely to be selected than applicants without a migration background and with pre-university education. These effects did not vary across programs. More variability in effects was found between different selection tools. Compared to women, men performed significantly poorer on CVs, while they had higher scores on biomedical knowledge tests. Applicants with a non-Western migration background scored lower on curriculum-sampling tests. First-generation Western immigrants had lower CV-scores. First-generation university applicants had significantly lower pe-GPAs. There was a variety in effects for applicants with different alternative forms of prior education. For curriculum-sampling tests and CVs, effects varied across programs. Our findings highlight the need for continuous evaluation, identifying best practices within existing tools, and applying alternative tools.

Performance of Automated ASPECTS Software and Value as a Computer-Aided Detection Tool

BACKGROUND AND PURPOSE

ASPECTS quantifies early ischemic changes in anterior circulation stroke on NCCT but has interrater variability. We examined the agreement of conventional and automated ASPECTS and studied the value of computer-aided detection.

MATERIALS AND METHODS

We retrospectively collected imaging data from consecutive patients with acute ischemic stroke with large-vessel occlusion undergoing thrombectomy. Five raters scored conventional ASPECTS on baseline NCCTs, which were also processed by RAPID software. Conventional and automated ASPECTS were compared with a consensus criterion standard. We determined the agreement over the full ASPECTS range as well as dichotomized, reflecting thrombectomy eligibility according to the guidelines (ASPECTS 0-5 versus 6-10). Raters subsequently scored ASPECTS on the same NCCTs with assistance of the automated ASPECTS outputs, and agreement was obtained.

RESULTS

For the total of 175 cases, agreement among raters individually and the criterion standard varied from fair to good (weighted κ = between 0.38 and 0.76) and was moderate (weighted κ = 0.59) for the automated ASPECTS. The agreement of all raters individually versus the criterion standard improved with software assistance, as did the interrater agreement (overall Fleiss κ = 0.15-0.23; P < .001 and .39 to .55; P = .01 for the dichotomized ASPECTS).

CONCLUSIONS

Automated ASPECTS had agreement with the criterion standard similar to that of conventional ASPECTS. However, including automated ASPECTS during the evaluation of NCCT in acute stroke improved the agreement with the criterion standard and improved interrater agreement, which could, therefore, result in more uniform scoring in clinical practice.

Understanding of healthcare professionals towards the roles and competencies of clinical pharmacists in South Africa

BACKGROUND

Incorporating clinical pharmacists in collaborative medical teams results in better patient treatment and health outcomes. In addition, the understanding of other healthcare professionals (HCPs) towards the role of clinical pharmacists can either facilitate or hinder the implementation and expansion of these services. The main distinction between pharmacists and clinical pharmacists lie in their different scope of duties. This study set out to explore other HCPs' understanding towards the role of the clinical pharmacists in South Africa, and to identify associated factors.

METHODS

An exploratory, survey-based, quantitative study was conducted. A survey assessing HCPs' understanding based on the competencies and role of a clinical pharmacist was distributed to 300 doctors, nurses, pharmacists and clinical pharmacists. An exploratory factor analysis was carried out to determine the construct validity of the measurement. Items were analysed for grouping into subscales through principal components analysis. Differences in the variable scores for gender, age, work experience and previous experience working with a clinical pharmacist were analyzed using independent t-tests. Analysis of variance was used to analyze differences in the variable scores for the different HCPs and the different departments of work in the hospital.

RESULTS

The factor analysis yielded two separate subscales, measuring HCPs' (n = 188) understanding towards the role of a clinical pharmacist, as well as the competencies of a clinical pharmacist. Doctors (85, n = 188) (p = 0.004) and nurses (76, n = 188) (p = 0.022), working in both surgical and non-surgical units, had significantly poorer understanding of the role of clinical pharmacists than clinical pharmacists (8, n = 188) and pharmacists (19, n = 188) (p = 0.028). Where specific clinical pharmacist activities were described, 5-16% of pharmacists were unsure whether an activity forms part of a clinical pharmacist's role. Over 50% of the clinical pharmacists disagreed that their role also includes pharmacist's activities, like stock procurement and control, pharmacy and administrative work, and hospital pharmacy-medication dispensing activities.

CONCLUSION

The findings highlighted the possible impact of role expectations and lack of understanding among HCPs. A standard job description with recognition from statutory bodies could promote other HCPs, as well as clinical pharmacists' understanding of their roles. Findings further suggested the need for interventions like interprofessional education opportunities, staff induction programmes and regular interprofessional meetings to foster acknowledgement of clinical pharmacy services, promoting the acceptance and growth of the profession.

Usefulness of different screening questionnaires and scoring systems for obstructive sleep apnea in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital.

OnBehalf

Research Group Cardiovascular Diseases, University of Antwerp

Background

Obstructive sleep apnea (OSA) influences the progression of atrial fibrillation (AF) but is underdiagnosed in this population. Studies have shown that its treatment can help to reduce AF recurrences and improve symptoms. Polysomnography (PSG) is currently the gold standard for diagnosing OSA but being expensive and requiring overnight examination it is therefore not the ideal screening method. Different OSA screening tools such as questionnaires and scoring systems already exist but their value in AF patients remains unclear.

Purpose

The aim of this study was to examine the performance of different screening questionnaires and scoring systems for diagnosing OSA in an AF cohort, compared with PSG as gold standard.

Methods

Prospective study of the predictive performance of seven screening questionnaires and scoring systems (the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire (BQ), Sleep Apnea Clinical Score (SACS), OSA50, STOP-BANG, NoSAS, MOODS) in consecutive AF patients referred to two sleep clinics.

Results

A total of 100 AF patients presenting for PSG were included (64.0 ± 8.6 years, 73% male, 87% non-permanent AF, mean Body Mass Index 30.6 ± 5.9 kg/m2, mean CHA2DS2-VASc score 2.4 ± 1.7, mEHRA≥2 in 64%; mean AF history 5.4 ± 5.6 years).  Forty-two percent of patients were referred to the sleep clinic by cardiologists. PSG diagnosed ≥mild OSA in 90% of patients, ≥moderate in 69%, and severe OSA in 33%. In screening for mild OSA, NoSAS, STOP-BANG and MOODS screening questionnaires had a fair area under the curve (AUC) of 0.773, 0.710 and 0.709 respectively. For at least moderate OSA, only the SACS and the NoSAS questionnaires had an AUC of 0.704 and 0.712 respectively (Figure 1). None of the seven screening questionnaires/scoring systems were performant enough (i.e. a fair AUC &gt; 0.7) to detect severe OSA.

Conclusions

Our analysis shows that screening questionnaires and scoring systems such as ESS, BQ, SACS, NoSAS, OSA50, STOP-BANG and MOODS are not very useful to predict clinically relevant OSA (i.e. at least moderate OSA) in AF patients. Therefore, other screening modalities for OSA in AF patients should be investigated and validated. Abstract Figure 1

Polypharmacy, functional outcome and treatment effect of intravenous alteplase for acute ischaemic stroke

BACKGROUND AND PURPOSE

Polypharmacy is an important challenge in clinical practice. Our aim was to determine the effect of polypharmacy on functional outcome and treatment effect of alteplase in acute ischaemic stroke.

METHODS

This was a post hoc analysis of the randomized, placebo-controlled WAKE-UP trial of magnetic resonance imaging guided intravenous alteplase in unknown onset stroke. Polypharmacy was defined as an intake of five or more medications at baseline. Comorbidities were assessed by the Charlson Comorbidity Index (CCI). The primary efficacy variable was favourable outcome defined by a score of 0-1 on the modified Rankin Scale at 90 days. Logistic regression analysis was used to test for an association of polypharmacy with functional outcome, and for interaction of polypharmacy and the effect of thrombolysis.

RESULTS

Polypharmacy was present in 133/503 (26%) patients. Patients with polypharmacy were older (mean age 70 vs. 64 years; p < 0.0001) and had a higher score on the National Institutes of Health Stroke Scale at baseline (median 7 vs. 5; p = 0.0007). A comorbidity load defined by a CCI score ≥ 2 was more frequent in patients with polypharmacy (48% vs. 8%; p < 0.001). Polypharmacy was associated with lower odds of favourable outcome (adjusted odds ratio 0.50, 95% confidence interval 0.30-0.85; p = 0.0099), whilst the CCI score was not. Treatment with alteplase was associated with higher odds of favourable outcome in both groups, with no heterogeneity of treatment effect (test for interaction of treatment and polypharmacy, p = 0.29).

CONCLUSION

In stroke patients, polypharmacy is associated with worse functional outcome after intravenous thrombolysis independent of comorbidities. However, polypharmacy does not interact with the beneficial effect of alteplase.

OP0291 TOFACITINIB FOR THE TREATMENT OF POLYARTICULAR COURSE JUVENILE IDIOPATHIC ARTHRITIS: RESULTS OF A PHASE 3, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED WITHDRAWAL STUDY

Background:

Tofacitinib is an oral JAK inhibitor that is being investigated for JIA.

Objectives:

To assess tofacitinib efficacy and safety in JIA patients (pts).

Methods:

This was a Phase 3, randomised, double-blind (DB), placebo (PBO)-controlled withdrawal study in pts aged 2−<18 years with polyarticular course JIA (pcJIA), PsA or ERA (NCT02592434). In the 18-week open-label Part 1, pts received weight-based tofacitinib doses (5 mg BID or lower). Pts with ≥JIA ACR30 response at Week (W)18 were randomised 1:1 in the DB Part 2 (W18−44) to continue tofacitinib or switch to PBO. Primary endpoint: disease flare rate by W44. Key secondary endpoints: JIA ACR50/30/70 response rates; change from Part 2 baseline (Δ) in CHAQ-DI at W44. Other efficacy endpoints: time to disease flare in Part 2; JADAS27-CRP in Parts 1 and 2. PsA/ERA pts were excluded from these efficacy analyses. Safety was evaluated in all pts up to W44.

Results:

225 enrolled pts with pcJIA (n=184), PsA (n=20) or ERA (n=21) received tofacitinib in Part 1. At W18, 173/225 (76.9%) pts entered Part 2 (pcJIA n=142, PsA n=15, ERA n=16). In pcJIA pts, disease flare rate in Part 2 was significantly lower with tofacitinib vs PBO by W44 (p=0.0031; Fig 1a). JIA ACR50/30/70 response rates (Fig 1b) and ΔCHAQ-DI (Fig 1c) at W44, and time to disease flare in Part 2 (Fig 2a), were improved with tofacitinib vs PBO. Tofacitinib reduced JADAS27-CRP in Part 1; this effect was sustained in Part 2 (Fig 2b). Overall, safety was similar with tofacitinib or PBO (Table): 77.3% and 74.1% had adverse events (AEs); 1.1% and 2.4% had serious AEs. In Part 1, 2 pts had herpes zoster (non-serious) and 3 pts had serious infections (SIs). In Part 2, SIs occurred in 1 tofacitinib pt and 1 PBO pt. No pts died.

Conclusion:

In pcJIA pts, tofacitinib vs PBO resulted in significantly fewer disease flares, and improved time to flare, disease activity and physical functioning. Tofacitinib safety was consistent with that in RA pts.

Table.

Safety in all pts

Part 1Part 2TofacitinibaN=225TofacitinibaN=88PBO N=85Pts with events, n (%)AEs153 (68.0)68 (77.3)63 (74.1)SAEs7 (3.1)1 (1.1)2 (2.4)Permanent discontinuations due to AEs26 (11.6)16 (18.2)29 (34.1)AEs of special interest Death000 Gastrointestinal perforationb000 Hepatic eventb3 (1.3)00 Herpes zoster (non-serious and serious)2 (0.9)c00 Interstitial lung diseaseb000 Major adverse cardiovascular eventsb000 Malignancy (including non-melanoma skin cancer)b000 Macrophage activation syndromeb000 Opportunistic infectionb000 SI3 (1.3)1 (1.1)d1 (1.2) Thrombotic event (deep vein thrombosis, pulmonary embolismbor arterial thromboembolism)000 Tuberculosisb000

a5 mg BID or equivalent weight-based lower dose in pts <40 kg

bAdjudicated events

cBoth non-serious

dOne SAE of pilonidal cyst repair was coded to surgical procedures instead of infections, and was inadvertently not identified as an SI. Following adjudication, the SAE did not meet opportunistic infection criteria; it is also included in the table as an SI

AE, adverse event; BID, twice daily; PBO, placebo; pts, patients; SAE, serious AE; SI, serious infection

Acknowledgments:

Study sponsored by Pfizer Inc. Medical writing support was provided by Sarah Piggott of CMC Connect and funded by Pfizer Inc.

Disclosure of Interests:

Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Olga Synoverska Speakers bureau: Sanofi, Tracy Ting: None declared, Carlos Abud-Mendoza Speakers bureau: Eli Lilly, Pfizer Inc, Alberto Spindler Speakers bureau: Eli Lilly, Yulia Vyzhga Grant/research support from: Pfizer Inc, Katherine Marzan Grant/research support from: Novartis, Vladimir Keltsev: None declared, Irit Tirosh: None declared, Lisa Imundo: None declared, Rita Jerath: None declared, Daniel Kingsbury: None declared, Betül Sözeri: None declared, Sheetal Vora: None declared, Sampath Prahalad Grant/research support from: Novartis, Elena Zholobova Grant/research support from: Novartis and Pfizer Inc, Speakers bureau: AbbVie, Novartis, Pfizer Inc and Roche, Yonatan Butbul Aviel: None declared, Vyacheslav Chasnyk: None declared, Melissa Lerman Grant/research support from: Amgen, Kabita Nanda Grant/research support from: Abbott, AbbVie, Amgen and Roche, Heinrike Schmeling Grant/research support from: Janssen, Pfizer Inc, Roche and USB Bioscience, Heather Tory: None declared, Yosef Uziel Speakers bureau: Pfizer Inc, Diego O Viola Grant/research support from: Bristol-Myers Squibb, GSK, Janssen and Pfizer Inc, Speakers bureau: AbbVie and Bristol-Myers Squibb, Holly Posner Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Keith Kanik Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ann Wouters Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cheng Chang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Richard Zhang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Irina Lazariciu Consultant of: Pfizer Inc, Employee of: IQVIA, Ming-Ann Hsu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ricardo Suehiro Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Alberto Martini Consultant of: AbbVie, Eli Lily, EMD Serono, Janssen, Novartis, Pfizer, UCB, Daniel J Lovell Consultant of: Abbott (consulting and PI), AbbVie (PI), Amgen (consultant and DSMC Chairperson), AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb (PI), Celgene, Forest Research (DSMB Chairman), GlaxoSmithKline, Hoffman-La Roche, Janssen (co-PI), Novartis (consultant and PI), Pfizer (consultant and PI), Roche (PI), Takeda, UBC (consultant and PI), Wyeth, Employee of: Cincinnati Children’s Hospital Medical Center, Speakers bureau: Wyeth, Hermine Brunner Consultant of: Hoffman-La Roche, Novartis, Pfizer, Sanofi Aventis, Merck Serono, AbbVie, Amgen, Alter, AstraZeneca, Baxalta Biosimilars, Biogen Idec, Boehringer, Bristol-Myers Squibb, Celgene, EMD Serono, Janssen, MedImmune, Novartis, Pfizer, and UCB Biosciences, Speakers bureau: GSK, Roche, and Novartis

[Management of chronic osteomyelitis by long-term antibiotic suppression]

Chronic osteomyelitis is a chronic inflammatory disease induced by bone infection. It may be limited to a single portion of bone or involve several areas such as marrow, cortical, periosteum and adjacent soft tissues. Being able to persist for weeks, months or even years, it remains a therapeutic challenge in spite of the important medical and surgical advances, with a prolonged and complex management given the nature of the surgical interventions and the antibiotherapies required. We report a case of chronic osteomyelitis treated by long-term suppressive antibiotic therapy, which may be a reasonable alternative to surgery in inoperable clinical situations, but taking into account the risks associated with it in terms of side effects and selection of resistant organisms, as well as the cost of treatment and the quality of life of the patient.

A multi-site study on medical school selection, performance, motivation and engagement

Medical schools seek ways to improve their admissions strategies, since the available methods prove to be suboptimal for selecting the best and most motivated students. In this multi-site cross-sectional questionnaire study, we examined the value of (different) selection procedures compared to a weighted lottery procedure, which includes direct admission based on top pre-university grade point averages (≥8 out of 10; top-pu-GPA). We also considered whether students had participated in selection, prior to being admitted through weighted lottery. Year-1 (pre-clinical) and Year-4 (clinical) students completed standard validated questionnaires measuring quality of motivation (Academic Self-regulation Questionnaire), strength of motivation (Strength of Motivation for Medical School-Revised) and engagement (Utrecht Work Engagement Scale-Student). Performance data comprised GPA and course credits in Year-1 and clerkship performance in Year-4. Regression analyses were performed. The response rate was 35% (387 Year-1 and 273 Year-4 students). Top-pu-GPA students outperformed selected students. Selected Year-1 students reported higher strength of motivation than top-pu-GPA students. Selected students did not outperform or show better quality of motivation and engagement than lottery-admitted students. Participation in selection was associated with higher engagement and better clerkship performance in Year-4. GPA, course credits and strength of motivation in Year-1 differed between students admitted through different selection procedures. Top-pu-GPA students perform best in the medical study. The few and small differences found raise questions about the added value of an extensive selection procedure compared to a weighted lottery procedure. Findings have to be interpreted with caution because of a low response rate and small group sizes.

Spotlight on Volasertib: Preclinical and Clinical Evaluation of a Promising Plk1 Inhibitor

Considering the important side effects of conventional microtubule targeting agents, more and more research focuses on regulatory proteins for the development of mitosis-specific agents. Polo-like kinase 1 (Plk1), a master regulator of several cell cycle events, has arisen as an intriguing target in this research field. The observed overexpression of Plk1 in a broad range of human malignancies has given rise to the development of several potent and specific small molecule inhibitors targeting the kinase. In this review, we focus on volasertib (BI6727), the lead agent in category of Plk1 inhibitors at the moment. Numerous preclinical experiments have demonstrated that BI6727 is highly active across a variety of carcinoma cell lines, and the inhibitor has been reported to induce tumor regression in several xenograft models. Moreover, volasertib has shown clinical efficacy in multiple tumor types. As a result, Food and Drug Administration (FDA) has recently awarded volasertib the Breakthrough Therapy status after significant benefit was observed in acute myeloid leukemia (AML) patients treated with the Plk1 inhibitor. Here, we discuss both preclinical and clinical data available for volasertib administered as monotherapy or in combination with other anticancer therapies in a broad range of tumor types.

Preclinical and clinical studies on afatinib in monotherapy and in combination regimens: Potential impact in colorectal cancer

Targeting the epidermal growth factor receptor (EGFR) with monoclonal antibodies (mAbs) or tyrosine kinase inhibitors (TKI) has been an interesting therapeutic strategy because aberrant activation of this receptor plays an important role in the tumorgenesis of many cancer types, including colorectal cancer (CRC). After the initial promising results of EGFR-targeted therapies, therapeutic resistance is a major clinical problem. In order to overcome resistance to these EGFR-targeted therapies, new treatment options are necessary. In contrast to first generation EGFR inhibitors, afatinib (BIBW2992) is a second-generation irreversible ErbB family blocker that inhibits EGFR as well as HER2 and HER4. Consequently, treatment with afatinib may result in a distinct and more pronounced therapeutic benefit. Preclinical studies have reported promising results for afatinib in monotherapy as well as in combination with other drugs in CRC model systems. Furthermore, clinical studies examining afatinib as single agent and in combination therapy demonstrated manageable safety profile. Nevertheless, only limited antitumor activity has been observed in CRC patients. Although several combination treatments with afatinib have already been investigated, no optimal combination has been identified for CRC patients yet. As molecular tumor characteristics have gained increased importance in the choice of treatment, additional studies with biomarker-driven patient recruitment are required to further explore afatinib efficacy in CRC.

Computertomografie voor de detectie van longnodulen bij de hond

Computertomografie is de laatste jaren meer en meer beschikbaar in de diergeneeskunde. Een belangrijke toepassing is de detectie van longnodulen bij kankerpatiënten. Het vroegtijdig opsporen is essentieel voor het bepalen van de therapie en de prognose van de ziekte. In dit artikel worden het gebruik, de meerwaarde en de beperkingen van deze beeldvormingstechniek beschreven.

[Are the concerns regarding metal-on-metal total hip arthroplasties founded in 2012?]

Metal-on-metal total hip arthroplasty (MOM THA) fuels debate in the orthopedic community after statistics showed higher-than-expected short-term failures in comparison with metal-on-polyethylene THA. The problem of early failure in the young, active patient with a metal-on-polyethylene implant has prompted the research of another couple. Multiple studies showed the advantages of MOM THA. The results of MOM resurfacing and MOM THA in our hospital did not show concerning results. Nonetheless, the data in the literature shows divergent opinions. The most recent statistics indicate that the results are disappointing, particularly with specific types of implants. Several institutions, in the USA and in Europe, are developing protocols for the follow-up of patients with MOM hip implants. Today, we are headed towards imposing a moratorium on using MOM THA.

[Surgical management of duodenal ulcer with hemorrhage from the gastroduodenal artery: antrectomy versus conservative surgery?]

When surgery is indicated for bleeding duodenal ulcer, the traditional standard of care has been "radical surgical treatment is preferable to conservative therapy since the risk of rebleeding is reduced without an augmentation in morbidity and mortality". This principle is based on two prospective studies published before 1995. Radical surgery at that time consisted of antrectomy, while conservative therapy included oversewing of the bleeding vessel in the ulcer bed and ligation of the gastroduodenal artery (Weinberg procedure). This strategy must be re-evaluated in 2008 in view of our better understanding of the role of Helicopacter pylori in the causation of duodenal ulceration and the decreased risk of post-operative re-bleeding with the use of proton pump inhibitors. The role of surgery has changed. Its aim is no longer to cure the ulcer diathesis but rather to urgently control bleeding in anticipation of ulcer cure with medical therapy.

Stress responses to tilting and odor stimulus in preterm neonates after intrauterine conditions associated with chronic stress

The effect of conditions linked with chronic intrauterine stress (CIUSTR) on the function of the autonomic nervous system (ANS) has not yet been evaluated systematically in premature neonates. We hypothesized that intrauterine stress deranges the function of the ANS as assessed by the clinical responses to certain stimuli. Twenty-one premature neonates who had suffered from CIUSTR, such as maternal smoking, maternal hypertension, and intrauterine growth retardation (STR Group), and 30 neonates who had not suffered from those intrauterine conditions were studied (C Group). They were exposed to a 10-s postural change test and a 10-s odor test. Heart rate, respiratory rate, and noninvasive blood pressure were measured at 15 s, 30 s, and at 1, 2, 3, 4, and 5 min after the test. The overall reaction pattern after the postural change test was mainly sympathetic, and was more pronounced in the STR Group. After the odor test, the overall response was parasympathetic but less pronounced in the STR Group. We, therefore, speculate that neonates who suffer from conditions known to be associated with CIUSTR exhibit a higher adrenergic state with little reserve to counteract stressful situations that may make them more vulnerable.

Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria

This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed.

Stress responses in preterm neonates after normal and at-risk pregnancies

OBJECTIVE

To evaluate the autonomic response in preterm neonates born after an at-risk pregnancy.

METHODOLOGY

Twenty-one preterm neonates (gestational age; GA) 29-37 weeks; bodyweight (BW): 720-2113 g; postnatal age: 2-126 days), born after at-risk pregnancies (stressed (STR) group), were compared to 30 preterm neonates (GA: 26-36 weeks; BW: 813-2380 g: postnatal age: 2-86 days) without any intrauterine risk factor (C group). A 10 s pain stimulus was given on the forefoot and heart rate, respiratory rate and blood pressure were measured at 15 and 30 s, at 1, 2, 3, 4 and 5 min. After 10 s ocular compression six cardiac variables were recorded.

RESULTS

After the pain stimulus the STR-group had a significant increase of heart rate at 15 s and an increase of diastolic blood pressure at 30 s. In the C group a significant increase of heart rate at 15 s was recorded. For the respiratory rate both groups showed an initial depression (significant at 15 s in the C group) followed by an increase. The time to react to the ocular compression was significantly shorter in the STR-group than in the C-group and thus more parasympathetic.

CONCLUSIONS

We hypothesize that the different sympathetic and parasympathetic reaction patterns of the vital parameters to triggers in the STR-group are due to chronic stress, pointing to an altered maturation of the two components of the autonomic nervous system after chronic intrauterine stress (CIUSTR).

Clinical defense response to cold and noise in preterm neonates after intrauterine conditions associated with chronic stress

Threatening stimuli may trigger abnormal reaction patterns in animals and infants. We investigated whether chronic intrauterine stress influenced these reactions. The autonomic defense response to cold and noise in 21 preterm newborns who had suffered from chronic intrauterine stress, such as maternal smoking, maternal hypertension, and intrauterine growth retardation (STR-group) was compared with the response in 30 preterm newborns without such condition (C-group). An ice cube was applied to the forehead and a 90 dB bleeptone was presented to the ears. After the cold test the heart rate, systolic, diastolic, and mean blood pressure increased in both groups, but to a lesser extent in the STR-group: the heart rate increased more at 2 minutes in the C-group (p = 0.009), and the systolic blood pressure was higher in the C-group at 30 seconds (p = 0.007). The respiratory rate decreased in both groups. After the auditory stimulus, no significant difference in response between the two groups was seen for any of the parameters. The number of arousals between the two groups was similar for both tests; they uniformly resulted in increased heart and respiratory rates. The classic passive defense response was not observed in either group of preterm newborns. The observed reaction could be defined as a combination of a sympathetic, active fight-or-flight reaction and a parasympathetic passive freezing, or paralysis, reaction. The latter was less pronounced in the C-group. This may point to a change in the maturation of the autonomic nervous system after chronic intrauterine stress. It is speculated that this could make these infants more vulnerable in stressful situations.

Cost recovery and improved drug availability in Niger--implications for total patient treatment costs

Using quasi-experimental design methods, this study investigated, for a cost recovery intervention in Niger, how the total costs of an episode of treatment for an acute illness for a typical patient changed when user fees were imposed but accompanied by an improved drug supply. Episode costs included both cash and opportunity costs. With few exceptions, the comparisons of both the unadjusted and adjusted patient episode costs showed that patient total episode costs in the intervention sites increased relative to the control site. The infusion of resources in Say and Boboye meant that now patients had essential medicines to buy, in comparison to Illela where stocks of essential medicines continued to deteriorate. Trends in episode costs within each intervention district demonstrated that to some extent cost recovery accompanied by an improved drug supply did not significantly change the total cost of an episode of treatment. In Say, this was true for malaria cases, females and the poor. However, in Boboye, reductions in copayments were offset by a mandatory tax payment paid by both users and non-users.

In situ biodegradation of poly(3-hydroxybutyrate) and poly(3-hydroxybutyrate-co-3-hydroxyvalerate) in natural waters

The biodegradation of samples of poly(3-hydroxybutyrate)(P(3HB)), poly(3-hydroxybutyrate-co-10%-3-hydroxyvalerate)(P(3HB-co-10 %-3HV)), and poly 3-hydroxybutyrate-co-20%-3-hydroxyvalerate)(P(3HB-co-20%- 3HV)) was investigated in situ in natural waters. The degradation was studied by decrease in mass, molecular weight, and tensile strength. In two freshwater ponds the polymers were slowly degraded. After half a year of submersion the mass loss was less than 7%. After 358 days in a freshwater canal, 34% mass loss was recorded for the homopolymer, and 77% for the P(3HB-co-10%-3-HV) samples, while the P(3HB-co-20%-3HV) samples had completely disappeared. In seawater in the harbour of Zeebrugge, P(3HB) samples lost 31% of their initial mass, and the copolymers 49-52%, within 270 days. In all of these environments, the degradation rate was faster during the summer, when the temperature of the water was higher. No relevant changes in molecular weight could be detected, indicating that the degradation took place only at the surface of the samples. The degradation resulted in considerable loss of tensile strength of the copolymer samples. Ninety-two microorganisms, mainly bacteria, able to degrade P(3HB) in polymer overlayer plates, were isolated and identified by fatty acid analysis. The isolates from one freshwater pond belonged mainly to the bacterial genus Acidovorax, while the microorganisms from the other freshwater pond belonged to various bacterial genera, to Streptomyces, and to the mould genus Penicillium. Most of the 31 bacterial isolates from seawater were identified as Alteromonas haloplanktis. The results demonstrate that P(3HB) and P(3HB-co-3HV) samples are effectively biodegradable in natural waters under real-life conditions and reveal the biodiversity of the microflora responsible for this biodegradation.

Improving quality through cost recovery in Niger

New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.

Microbial degradation of poly(3-hydroxybutyrate) and poly(3-hydroxybutyrate-co-3-hydroxyvalerate) in soils

The microbial degradation of tensile test pieces made of poly(3-hydroxybutyrate) [P(3HB)] or a copolymer of 90% 3-hydroxybutyric acid and 10% 3-hydroxyvaleric acid was studied in soils incubated at a constant temperature of 15, 28, or 40 degrees C for up to 200 days. In addition, hydrolytic degradation in sterile buffer at temperatures ranging from 4 to 55 degrees C was monitored for 98 days. Degradation was measured through loss of weight (surface erosion), molecular weight, and mechanical strength. While no weight loss was recorded in sterile buffer, samples incubated in soils were degraded at an erosion rate of 0.03 to 0.64% weight loss per day, depending on the polymer, the soil, and the incubation temperature. The erosion rate was enhanced by incubation at higher temperatures, and in most cases the copolymer lost weight at a higher rate than the homopolymer. The molecular weights of samples incubated at 40 degrees C in soils and those incubated at 40 degrees C in sterile buffer decreased at similar rates, while the molecular weights of samples incubated at lower temperatures remained almost unaffected, indicating that molecular weight decrease is due to simple hydrolysis and not to the action of biodegrading microorganisms. The degradation resulted in loss of mechanical properties. From the samples used in the biodegradation studies, 295 dominant microbial strains capable of degrading P (3HB) and the poly(3-hydroxybutyrate-co-3-hydroxyvalerate) copolymer in vitro were isolated and identified.(ABSTRACT TRUNCATED AT 250 WORDS)

The cost and efficiency of public and private health care facilities in Ogun State, Nigeria

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating a full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.

Biodegradation of polyhydroxyalkanoates

Degradation of poly(3-hydroxybutyrate) and copolymers with 3-hydroxyvaleric acid was investigated in natural environments, and the microorganisms involved were isolated and identified. The influence of abiotic and biotic factors on the degradation is discussed.

Guidelines for pragmatic assessment for health planning in developing countries

Although the primary health care strategy implemented since the Alma Ata declaration of 'health for all' appears to have contributed to improvements in selected health outcomes, the current ad hoc approach to health assessment and planning has impeded more substantial gains. A comprehensive yet pragmatic framework for country-level health programmers is needed that would permit consideration of the multiple steps involved in policy formulation and implementation. In the present paper, drawing upon an epidemiologic model (Iterative Measurement Loop) and an economic model (Cost-Effectiveness Analysis), we present guidelines for a pragmatic assessment for health planning. A format is provided for the conduct of these tasks which is operational in nature, is specific to the target country (or relevant region), can simultaneously consider multiple interventions, and is comprehensible to persons without sophisticated medical and/or economic backgrounds. Such a format enables articulation and consideration of local concerns as well as national and global considerations.

A diffusion-adsorption model for the computation of the amount of hormone around a secreting cell, detected by the reverse hemolytic plaque assay

The reverse hemolytic plaque assay enables the detection of secretion products from individual cells in cultures by visualizing the plaques formed after complement-mediated hemolysis around the secreting cells. However, the precise quantitation of the amount of secretion remains problematic. In this study we propose a computation model for estimating the spreading of the secreted molecules, based on the underlying processes of diffusion and antigen adsorption by immobilized antibodies. The translational diffusion coefficient of rat prolactin at 37 degrees C, determined by laser light scattering, was 9.89 x 10(-7) cm2/s. The time-dependent concentration distribution around a constantly secreting cell in a flat quasi infinite layer, was derived from the diffusion equation, using an analytical approach based on Laplace transformation. The relations between plaque size, incubation time and secretion level were expressed as a function of the threshold concentration of secretion product that can be detected and the effective diffusion coefficient, taking antigen adsorption into account. We obtained very good agreement between observed and predicted results for plaque formation by dispersed prolactin secreting cells of 14-day-old female rat pituitaries. This study confirms the validity of the assumptions underlying the reverse hemolytic plaque assay, provided that the cell density is low, the incubation time is moderately long and the concentration of specific antiserum is sufficiently high.

Multichannel microspectrofluorometry for topographic and spectral analysis of NAD(P)H fluorescence in single living cells

Starting from a previously described prototype microspectrofluorometer a more versatile apparatus has been developed with rapid optional operation on a topographic mode for the simultaneous multisite evaluation of NAD(P) reduction-reoxidation transients or on a spectral mode for the analysis of natural and exogenous fluorochromes, in single living cells. On the topographic mode, adetailed kinetic analysis of NAD or NAD P-linked dehydrogenases can be made from 50-100 cell points imultaneously via automatic recording of topographic scans upt to 16 times a second, in correlation with microelectrophoretic intracellular inuection of metabolites (e.g. nearly immediate response to glucose 6-phosphate, 20-25 s delay for 6-phosphogluconate). Rapid shifts from topographic to spectral operation make possible the detection of a change in fluorescence intensity at a specific intracellular site and the immediate verification of its nature (NAD(P)H or exogenous fluorochrome) by spectral observations.