Overcoming structural inequalities in oral health: the role of dental curricula.

To date the role of health professional schools in addressing oral health inequalities have been minimal, as attempts have focused principally upon systemic reform and broader societal obligations. Professionalism is a broad competency that is taught throughout dental schools and encompasses a range of attributes. Professionalism as a competency draws some debate and appears to be a shifting phenomenon. We may ask if professionalism in the dental curricula may be better addressed by social accountability? Social accountability directs oral health professional curricula (education, research, and service activities) towards addressing the priority health concerns of the community, in our case oral health inequalities. Although working toward dental schools becoming more socially accountable seems like a sensible way to address oral health inequalities, it might have limitations. We will consider some of the challenges in the dental curricula by considering some of the political, structural, social and ethical factors that influence our institutions and our graduates.

Quality councils as catalysts and leaders in quality improvement: the experience of the health quality council in Saskatchewan.

Quality councils are an increasingly common phenomenon in Canada. The Health Quality Council in Saskatchewan, the largest such council in Canada, is similar to other councils in that it reports publicly on quality of care, but it differs in that it has an explicit, central role to support quality improvement activities. The HQC strives to gain buy-in and cooperation from provider groups, even those identified as having suboptimal care, by offering them quality improvement training, measurement tools, information about best practices and advice from experts in change management, group psychology, process redesign and operations research. Developing relationships with stakeholders is a very labour- intensive process, but it is essential to fostering a blame-free culture of quality improvement. The HQC works with senior leaders to help coordinate province-wide priorities for quality improvement and with middle managers and frontline staff to establish local quality improvement teams. It does not alter the structure of existing accountability relationships; rather, it tries to make the dialogue more quality-focused. Its largest-scale activity is a Learning Collaborative involving 20% of all family physicians in the province in an effort to improve chronic disease management. The HQC believes that these targeted, coordinated activities in quality improvement will ultimately be far more effective than simply releasing reports or making recommendations.

The ethics of research related to health care in developing countries.

The Ethics of Research Related to Health Care in Developing Countries by the Nuffield Council on Bioethics makes a number of innovative recommendations that depart from codes such as the Declaration of Helsinki. It recommends that standards of care might be relativised to the standard of that nation. It recommends that very good reasons need to be given for not giving post-trial access to medications but recognises that there may be justifiable instances of this. It is the view of the authors that these and other recommendations of the report are sensible pieces of advice given the complexities of the developing world.

Allocating fertility services by medical need.

Infertility services often receive little or no public funding because they are perceived not to meet a medical need. This article argues that it is plausible to think of fertility treatment as a medical need. Medical needs deserve serious consideration in resource allocation. Such needs arise when there is a disruption of normal species function (disease), which results in a limitation of fair equality of opportunity. Fair equality of opportunity is important because it is required for a person's ability to live a good life. Infertility can result in a medical need because it can be a disruption of normal species function and can result in diminished opportunity, which it is highly relevant to the conception of a good life of many people. Infertility services deserve serious consideration in resource allocation.

Effects of beacon administration on energy expenditure and substrate utilisation in Psammomys obesus (Israeli sand rats).

OBJECTIVE: To investigate whether beacon administration affects substrate utilisation, physical activity levels or energy expenditure in Psammomys obesus. DESIGN: Pairs of age- and sex-matched Psammomys obesus were randomly assigned to either beacon-treated (15 microg/day for 7 days (i.c.v.)) or control (i.c.v. saline) groups. MEASUREMENTS: Indirect calorimetry on day 0 and day 7 to measure oxygen consumption and carbon dioxide production, which were used to calculate fat oxidation, carbohydrate oxidation and total energy expenditure. Physical activity in the calorimeter was measured using an infrared beam system. Food intake and body weight were measured daily. RESULTS: The administration of beacon significantly increased body weight compared to saline-treated control animals. This body weight gain was primarily due to increased body fat content. Average daily food intake tended to be higher in beacon-treated Psammomys obesus, but no effect of beacon administration on substrate oxidation, activity or energy expenditure was detected. CONCLUSION: The effects of beacon on body weight are due to increased food intake, with no detectable effect on nutrient partitioning, physical activity or energy expenditure.

The impact of implementing a more restrictive prescription limit on Medicaid recipients. Effects on cost, therapy, and out-of-pocket expenditures.

On November 1, 1991, the Georgia Department of Medical Assistance reduced the maximum number of monthly reimbursable prescriptions from six to five. This policy change provided a natural experiment to investigate the recipient responses to a decrease in an existing prescription limit. The research design was a quasiexperimental, retrospective, 12-month interrupted time-series analysis of a cohort. The cohort consisted of 743 ambulatory recipients who were high prescription users. Complete Medicaid claims data were obtained, in addition to pharmacy-generated computer profiles for all cohort recipients to determine Medicaid and out-of-pocket prescriptions expenditures. Interrupted time-series analyses were performed to model the effect of the five-prescription limit on total, Medicaid-reimbursed, out-of-pocket, and prescription use across eight therapeutic categories. After the implementation of the five-prescription limit, total prescription use fell 6.6%, prescriptions reimbursed by Medicaid fell 9.9%, and prescriptions paid for out-of-pocket increased 9.7%. Abrupt, permanent decreases were observed for cardiovascular, miscellaneous, pulmonary, and palliative therapeutic drug categories (alpha = 0.05), whereas gastrointestinal, chemotherapy, hormone (insulin), and central nervous system prescription use remained constant. The implementation of a more restrictive prescription limit alters prescription regimens potentially predisposing elderly Medicaid recipients to clinical consequences. Further examination of the health outcomes of these recipients is necessary.

Public perceptions of brain tumours in Scotland: the need for access to appropriate information.

The aim of the study was to evaluate knowledge and perceptions of brain tumours in a heterogeneous, highly educated group of adults living in Edinburgh. Two hundred and forty four respondents answered a questionnaire about the causes, effects and treatments of brain tumours. There were misconceptions about several clinical and biological aspects of intracranial tumours although most respondents were aware of the bleak prognosis associated with many neoplasms. These results, from the intellectual elite of Scotland's capital, suggest that access to information about brain tumours should be readily available. Five leaflets, covering various aspects of brain tumours, that are available through the recently established Scottish charity Brain Tumour Action seem well formulated to address areas of concern and misconception.

Political freedom and the response to economic incentives: labor migration in Africa, 1972-1987.

PIP: This study examines the thesis that political institutions and the freedoms and civil rights generated by these institutions affect migration decisions. The hypothesis is based on one stated by Adam Smith in 1776, that economic conditions that reflect greater political freedoms and civil liberties harbor higher levels of resource mobility in response to economic incentives. Pooled cross-sectional and time-series analysis is based on data from the World Bank for 32 African countries during 1972-87. Findings support the hypothesis that migration rate is more affected by the expected returns ratio to labor in countries where civil liberties are greater than in nations with fewer civil liberties. The implication, from the inclusion of institutional factors in the model, is that civil liberties have an indirect impact on the rate of labor migration out of agriculture in Africa. The impact is a mix of economic incentives and civil liberties. In the political rights model, the most free countries had the largest migration elasticity. The findings on political rights impacts support findings by Friedman and McMillan that civil liberties are a more important determinant of economic growth than political rights. Further testing for measurement error confirmed that the data were flawed, but not so greatly that the basic findings were overturned. The migration out of African agriculture was found to be sensitive to the effect of price signals, which were conditioned by the degree of political rights and civil liberties. Policy makers are urged to consider both changes in pricing and institutions.^ieng

Prevalence of migraine headache and association with sex, age, race, and rural/urban residence: a population-based study of Georgia Medicaid recipients.

The estimates of migraine headache prevalence vary widely and fluctuate with the population examined and the methodologic factors used in studies examining this condition. As an alternative to survey techniques, a retrospective review of Medicaid claims data from 22 continuous months (January 1, 1989, to October 31, 1990) was used to detect medical episodes and physician-initiated pharmacologic therapy indicative of migraine headache. Specifically, the objectives of this study were to measure the prevalence of migraine headache in Georgia Medicaid recipients, estimate the prevalence in the US population, and describe the relationships between migraine and sociodemographic variables including sex, age, race, and rural versus urban residence. Logistic regression was used to isolate the independent effects of age, race, residence, and length of Medicaid eligibility on the presence or absence of migraine. The data consisted of adjudicated claims for 847,453 Georgia Medicaid recipients. Medicaid profiles for 678,079 recipients (468,448 female and 209,631 male) aged older than 4 years were analyzed as persons at risk of migraine. Migraine was identified in 6518 (1.39%) females and 991 (0.47%) males. Adjusting for eligibility, age, and race, the projected 22-month period prevalence for the United States was estimated as 3.83% (females) and 1.33% (males). Females, whites, and individuals residing in rural counties were more likely to suffer from migraine headache than their respective comparison groups. For both sexes, the peak prevalence was in the fourth and fifth decades of life. Migraine headache in the United States is estimated to afflict 4.5 million females and 1.4 million males. This prevalence is lower than previously reported and indicates that migraine headache may not be as common as previously believed. An alternative explanation is that many Medicaid recipients self-treat the condition, thus circumventing physician care and subsequent diagnosis and treatment.

Effect of drug interactions on outcomes of patients receiving warfarin or theophylline.

The effect of drug interactions on costs and other outcomes for hospitalized patients receiving warfarin or theophylline was studied. Data were collected from medical records during a one-year period in two community teaching hospitals in Maryland. The data included demographic information, the duration of study-drug therapy, the number of days spent in the intensive care unit, the length of stay (LOS) in the hospital, the number of prothrombin-time tests and serum theophylline assays, and the test results. A multiple-regression procedure was used to compare outcomes of patients who were prescribed specific drugs interacting with warfarin or theophylline with those of patients who were not. Among warfarin-treated patients, there was a significant difference in each outcome measure (LOS, number of laboratory tests, and test results) between those who received an interacting drug and those who did not; mean LOS was 3.14 days longer in patients given an interacting drug. No significant differences in outcome measures were observed between the two groups of theophylline-treated patients. The cost of the increased LOS attributed to the presence of a drug interacting with warfarin was estimated to range from $779 to $1005 per hospitalization. The cost of additional prothrombin-time tests was estimated at $19-$50. Patients who received warfarin and an interacting drug had an increased LOS, required more laboratory tests, and had longer prothrombin times than patients given warfarin alone; these differences probably led to higher costs.

Drug information and educational needs. A survey of rural home health care nurses.

In a study of rural home healthcare nurses' drug information and educational needs, data were collected from 40 nurses employed by a community-based public home health agency. The most serious drug-related problem identified by the nurses was patients' failure to receive prescribed drugs. The ten types of drug-related information included in the survey were viewed as very useful. The most frequently used sources of drug-related information were reference books, other nurses, and pharmacists.

Hardcopy recording technologies for digitally formatted image data.

The hardcopy recording technologies of video cameras, slow-scan (digital spot) recorders, and laser film printers are presented and compared. Slow-scan (digital spot) recorders offer a few advantages when compared with multiformat video cameras. But only laser film printers provide the high-quality hardcopy recordings and speed required by newer digital imaging modalities.

Teleradiology: an assessment.

A teleradiology system acquires radiographic images at one location and transmits them to one or more remote sites, where they are displayed and/or converted to hard copy. These systems often employ wide area networks. Their goal is to provide improved radiologic services at all sites on the network. Experience in the use of teleradiology systems has demonstrated the need for a laser film digitizer, an optical disk, and a high-quality display and/or laser film printer at each site. Single-site hardware purchase costs average $196,000, plus an additional 20% for yearly network services. Hardware purchased for a consultation or central referral facility approximates $344,000.

Assessment of cardiac size on portable chest films.

Using both anthropomorphic phantoms and human patients, the authors have shown that the effects on cardiothoracic (CT) ratio of changing from the posteroanterior (PA) to the anteroposterior (AP) projection are much greater than the effect of reducing the anode-to-film distance (AFD). This is because, in the AP projection, not only is the transverse diameter (TD) of the heart much farther from the film (and its image is therefore enlarged), but the TD of the chest is usually closer to the film and its image is reduced in size. These factors, operating in different directions, cause a major change in the CT ratio. The authors have shown that small hearts are magnified more than large hearts by changing from PA to AP, and that the position of the TD of the thorax (whether it is farther anterior or farther posterior) markedly affects what happens to the CT ratio when the AFD is changed. Because of this, it is impossible to predict accurately what effects a given AFD and projection will have on the CT ratio. However, using approximate correction factors (-12.5% of CT ratio for a 40 in AFD, AP film and -10% of CT ratio for a 72 in AFD, AP film) a clinically useful determination can be rapidly made as to whether the heart is enlarged or not.

Rapid detection of herpes simplex virus in MRC-5 cells using low-speed centrifugation enhancement and immunoperoxidase staining 16 h post-inoculation.

The performance of MRC-5 shell vial centrifugation-enhancement and direct immunoperoxidase staining was compared to the traditional WI38 tube cell culture for the detection of Herpes simplex virus on 123 clinical samples. The shell vial technology not only proved to be sensitive (100%) and specific (100%), but could offer up to 20% reduction in cost when compared to routine methods. In addition, a commercially prepared MRC-5 shell vial product proved to be superior with respect to cost, sensitivity, and reliability when compared to an in-house preparation.