Total Worker Health®: knowledge of a sample of Occupational Physicians and Prevention and Protection Service Managers.

Background: In the workplace, it is increasingly important to promote interventions to improve the work environment that can combine compliance with regulations related to worker health and safety protection with health promotion interventions. The objective of our study is to investigate the status of the implementation of various health management measures through questionnaires submitted to Occupational Physicians (OPs) and Prevention and Protection Service Managers (PPSMs). Methods: This study was conducted between September 2022 and November 2022. Healthcare professionals were invited to voluntarily answer the questions, administered through a Google form, of a standardized questionnaire (Cronbach's alpha=0.887) based on the study made by Hoge et al. (2019): the first part collected demographic information and the other four were relating to the state of implementation of interventions attributable to the Total Worker Health® approach. Results: 89 OPs and PPSMs were involved. The univariate and multivariate analysis shows that, overall, women and PPSMs have a higher degree of dissatisfaction related to various health management measures within companies; most workers are fairly satisfied with health and safety protection in the workplace; finally, according to healthcare professionals, aspects of primary prevention and work management/organization would need to be improved. Conclusions: This study shows that in Italian companies there is often no full application of Total Worker Health® principles. The affirmation of this approach, awareness should be raised, first and foremost, among employers, but also among prevention figures and consultants about all the benefits of Total Worker Health®: one among all, an 'economic' advantage.

A paradigm for understanding trust and mistrust in medical research: The Community VOICES study.

BACKGROUND: To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust. METHODS: A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%). RESULTS: Generally favorable attitudes toward research were expressed by a majority (85.3%), but many respondents expressed mistrust. Factor analysis yielded four specific domains of trust/mistrust, each of which was associated with different demographic variables: general trustworthiness (older age, not disabled); perceptions of discrimination (African American, Latino, Spanish language preference); perceptions of deception (prior research experience, African American); and perceptions of exploitation (less education). CONCLUSIONS: The four domains identified in the analysis provide a framework for understanding specific areas of research trust/mistrust among disparate study populations. This model offers a conceptual basis for the design of tailored interventions that target specific groups to promote trust of individual researchers and research institutions as well as to facilitate broader research participation.

Balance and walking in facioscapulohumeral muscular dystrophy: multiperspective assessment.

BACKGROUND: In the Facioscapulohumeral muscular dystrophy (FSHD), the association of ankle muscle impairment with knee, hip and abdominal weakness causes complex alterations of static (postural) and dynamic (walking) balance, increasing the risk of recurrent falls. Stereophotogrammetric system and body-worn gyroscopes were used to focus on locomotor capacity and upper body movements in FSHD patients respectively. No data have been reported about static balance (plantar pressure and stabilometric parameters) and dynamic balance (spatio-temporal parameters during walking) in patients with FSHD. Moreover it is not known if the balance involvement influences disability and quality of life (QoL) of these patients. AIM: The aim of this study is to quantitatively assess static and dynamic balance in FSHD patients and their influence on disability and QoL. DESIGN: Case control-study. SETTING: Outpatient Rehabilitation Department. POPULATION: Sixteen FSHD patients were compared with 16 matched healthy subjects. METHODS: A baropodometric platform was used to measure plantar pressure and centre of pressure in stance (static evaluation), and spatio-temporal parameters during walking (dynamic evaluation). These quantitative results in FSHD patients were also correlated with validated clinical (Clinical Severity Scale), performance (10m and 2 min Walking Test), disability (Berg Balance Scale, Rivermead Mobility Index) and quality of life (QoL) measures (SF-36, NASS). RESULTS: The patients moved the plantar pressure forward from hindfoot to forefoot. Static balance was significantly reduced in patients compared with healthy subjects. Dynamic evaluation of walking showed a significant reduction of velocity and step length in the patients, and a significant increase in step width. Dynamic and static parameters were significantly related to a reduction of 10 mWT performance while only dynamic parameters were strongly related to disability and QoL. CONCLUSION: FSHD patients present an abnormal static and dynamic balance and they show compensation strategies to avoid falling . The involvement of the dynamic balance worsens the physical aspects of QoL and induces disability. The involvement of static balance induces a reduction of the performance in brief distances. CLINICAL REHABILITATION IMPACT: The balance training should be considered in the rehabilitation program of FSHD patients; the compensation strategies adopted by these patients should be considered in the ankle foot orthosis treatment. The static and dynamic balance assessment in FSHD patients can be used in natural history studies.

Effectiveness of topical application of amino acids to chronic wounds: a prospective observational study.

OBJECTIVE: To evaluate whether the topical application of an amino acid dressing, Vulnamin, aids the management of chronic wounds. METHOD: A total of 160 patients with non-infected cutaneous chronic wounds were recruited. Before treatment, wound size was assessed using digital planimetry. Treatment lasted for a maximum of six weeks. Wound area measurements were repeated two and six weeks after starting treatment. RESULTS: There was a significant reduction in the mean wound area after two weeks (7.4 +/- 8.7cm2) and six weeks (4.6 +/- 6.3cm2) of treatment, when compared with baseline (11.2 +/- 12.1cm2, p<0.01). At the final follow up, 23% of patients (n=36) healed and 34% (n=54) achieved a greater than 60% reduction in wound size. Seventy-six per cent (n=120) achieved positive outcomes (defined as a greater than 40% reduction in the ulcer size). CONCLUSION: Although further investigations on the potential effects of this product on chronic wound healing are required, these data suggest it may promote healing in venous, pressure and diabetic ulcers.

Mobility assessment of patients with facioscapulohumeral dystrophy.

BACKGROUND: Facioscapulohumeral muscular dystrophy is the third most common form of inherited myopathies with a prevalence of 1:20,000. Since both muscle involvement and disease progression are heterogeneous and unpredictable, quantitative assessment tools are needed to evaluate the effects of pharmacological and physical training treatments. METHODS: The instrumented movement analysis of 12 patients with facioscapulohumeral dystrophy and 12 control subjects was conducted using a 9-camera stereophotogrammetric system and 2 force platforms. Subjects performed four tasks of different difficulties: arm movement, level walking, step ascending, and squatting. Manual muscle test, clinical severity scale and magnetic resonance imaging were used to clinically assess the patients. FINDINGS: Walking speed and centre of mass vertical displacement during squatting were reduced in patients and can be used to assess their motor capacity. Features common in the patient sample were: the reduction of shoulder range of motion, the excessive ankle plantar-flexion during walking and step ascending, and the reduction of knee flexion-extension moment during squatting. These parameters were correlated with magnetic resonance imaging results at relevant structure level and can be used to assess the corresponding body functioning. Furthermore, instrumented movement analysis was able to distinguish from normal controls also a group of patients in which clinical assessments did not show any obvious abnormalities and had been evaluated as normal. INTERPRETATION: The quantitative assessment tool devised in this study provides suitable information in terms of both motor capacity and impairment severity of patients with facioscapulohumeral dystrophy, and, thus, encouraging its use for the evaluation of therapeutic trial outcomes for this disease.

Perceived outcomes of public health privatization: a national survey of local health department directors.

Almost three quarters of the nation's local health departments (LHDs) have privatized some services. About half of LHD directors who privatized services reported cost savings and half reported that privatization had facilitated their performance of the core public health functions. Expanded access to services was the most commonly reported positive outcome. Of those privatizing, over two-fifths of LHDs reported a resulting increase in time devoted to management. Yet, one-third of directors reported difficulty monitoring and controlling services that have been contracted out. Communicable disease services was cited most often as a service that should not be privatized. There is a pervasive concern that by contracting out services, health departments can lose the capacity to respond to disease outbreaks and other crises.

Privatization and the scope of public health: a national survey of local health department directors.

OBJECTIVES: This study sought to obtain and analyze nationally representative data on (1) privatization of local health department services, (2) local health department directors' beliefs and perspectives on the desirable role and focus of health departments, and (3) the influence of these views on privatization practices. METHODS: A stratified representative national sample of 380 local health department directors was drawn, and 347 directors were interviewed by telephone. Logistic regression established the independent effects of various factors on decisions to privatize. RESULTS: Almost three quarters (73%) of the local health departments privatized public health services of some type. The 12% of the directors who believed that local health departments should be restricted to the core public health functions and move entirely out of direct provision of personal health care were more likely to privatize services. The 77% of the directors who believed that local health departments should be involved in an increasing array of social problems were more likely to privatize. CONCLUSIONS: Privatization has quietly and quickly become commonplace in public health, and privatization practices are intimately related to divergent conceptions of public health and the role of local health departments.

Public attitudes regarding willingness to participate in medical research studies.

The recruitment of adequate numbers of people to participate in medical research studies is an ongoing problem for biomedical researchers. Although the general public has come to expect and demand that the biomedical community develop new, safe and effective approaches to the prevention and treatment of diseases, that same public is not aware of the important role that public participation plays in the development of medical advances. Much is known about willingness to participate in research studies from the perspectives of patients, survivors, and those at-risk for getting a particular disease. However, little is known about the attitudes and willingness of the general public to participate in medical research. Yet, it is this population that comprises the potential pool of participants for future treatment and prevention studies. In order to examine public attitudes toward and support for medical research, a random digit dial telephone survey was conducted with 489 persons in southwestern Pennsylvania. The survey measured the respondent's stated willingness to take part in a medical research study and the factors associated with willingness to participate. These included the respondent's health status, demographic characteristics, attitudes and beliefs about participation and their knowledge about the conduct of medical research. The results of the study indicate that 46% of those surveyed said that they would be willing to take part in a medical research study focusing on a new treatment for a specific disease that was of concern to them, 25% stated that they would not be willing and 29% stated that they were undecided regarding participation. However, under certain circumstances, such as having cancer, over half of those who were undecided said they would be willing to participate. The characteristics of those willing to participate in a medical research study differ from those not willing. Determinants of willingness include: having a relative or friend who has an illness, being middle aged (between 35-64 years old), prior experience with participation in a medical research study, having a favorable attitude toward the use of human subjects in medical research and beliefs that diverse types of persons participate in clinical trials. Those respondents who were undecided about joining a clinical trial, also have different characteristics than those who are not willing. The determinants of being undecided in contrast to not willing include: having at least a college degree, having a favorable or neutral attitude toward the use of humans in medical research and, believing that the well-being of participants is the primary concern of researchers. The findings of this study have both public policy and practice implications. From a policy perspective, medical research designed to develop new treatments for disease requires an evidenced-based approach for decision making. Such an approach can only succeed if adequate numbers of individuals are willing to participate in these studies. From a practice perspective, the current study suggests that opportunities exist to increase participation by targeting recruitment efforts not only toward the willing but also toward those who are undecided about participation in medical research studies. This would involve tailoring the content of communications to meet the specific characteristics and concerns of each of these two groups of individuals.

The impact of a Children's health insurance program by age.

OBJECTIVES: 1) To examine age variation in unmet need/delayed care, access, utilization, and restricted activities attributable to lack of health insurance in children before they receive health insurance; and 2) to examine the effect of health insurance on these indicators within each age group of children (in years). METHODS: We use cohort data on children before and after receiving health insurance. The study population consists of 750 children, 0 through 19 years of age, newly enrolling in two children's health programs. The families of the newly enrolled children were interviewed at the time of their enrollment (baseline), and again at 6 months and 1 year after enrollment. The dependent variables measured included access to regular provider, utilization, unmet need or delayed health care, and restrictions on activities attributable to health insurance status. All these indicator variables were examined by age groups (0-5, 6-10, 11-14, and 15-19 years of age). chi(2) tests were performed to determine whether these dependent variables varied by age at baseline. Using logistic regression, odds ratios were calculated for baseline indicators by age group of child, adjusting for variables commonly found to be associated with health insurance status and utilization. Changes in indicator variables from before to after receiving health insurance within each age group were documented and tested using the McNemar test. A comparison group of families of children enrolling newly 12 months later were interviewed to identify any potential effects of trend. RESULTS: All ages of children saw statistically significant improvements in access, reduced unmet/delayed care, dental utilization, and childhood activities. Before obtaining health insurance, older children, compared with younger children, were more likely to have had unmet/delayed care, to have not received health care, to have low access, and to have had activities limited by their parents. This pattern held for all types of care except dental care. Age effects were strong and independent of covariates. After being covered by health insurance, the majority of the delayed care, low utilization, low access, and limited activities in the older age groups (11-14 and 15-19 years) was eliminated. Thus, as levels of unmet need, delayed care, and limitations in activities approached zero in all age groups by 1 year after receipt of health insurance, age variation in these variables was eliminated. By contrast, age variation in utilization remained detectable yet greatly reduced. CONCLUSION: Health insurance will reduce unmet need, delayed care, and restricted childhood activities in all age groups. Health care professionals and policy makers also should be aware of the especially high health care delay, unmet need, and restricted activities experienced by uninsured older children. The new state children's health insurance programs offer the potential to eliminate these problems. Realization of this potential requires that enrollment criteria, outreach strategies, and delivery systems be effectively fashioned so that all ages of children are enrolled in health insurance.

Impact of a children's health insurance program on newly enrolled children.

CONTEXT: Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. OBJECTIVE: To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families. DESIGN: A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. SETTING: The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. SUBJECTS: A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. MAIN OUTCOME MEASURES: The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families. RESULTS: Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. CONCLUSIONS: Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.

The impact of lack of health insurance on children.

This paper examines the impact that the lack of health insurance has on children and their families. A random sample of families of children who were newly enrolled in a children's health insurance program were interviewed by telephone and asked about the children's health status, the amount of unmet need and delayed care for a number of services, consequences of unmet need and delayed care, usual activities, and the effect on the lack of health insurance. Data were analyzed by using both quantitative and qualitative methods. We found that uninsured children had experienced considerable unmet need and delayed care that increased as the time without insurance increased. The parents reported some adverse consequences. The children were also found to be limited in the extent to which they could participate in various activities specifically because they lacked health insurance. Finally, the parents reported considerable stress and worry associated with their children's lack of coverage. We conclude that being without health insurance has broad consequences for America's children.

Impact of free vaccine and insurance status on physician referral of children to public vaccine clinics.

CONTEXT: Concerns about financial barriers to vaccination led to the development of the Vaccines for Children (VFC) program, which provides free vaccines to states for children who are uninsured, Medicaid eligible, or Native American or Native Alaskan. OBJECTIVE: To understand the effect of economic factors on physician likelihood of referring children to public vaccine clinics for immunizations and to evaluate the VFC program. DESIGN: A standardized survey was conducted in 1995 by trained personnel using computer-assisted telephone interviewing. SETTING AND PARTICIPANTS: A stratified random sample of family physicians, pediatricians, and general practitioners younger than 65 years who were in office-based practices across the United States. MAIN OUTCOME MEASURES: Likelihood of referral of a child to a health department for vaccination by child's insurance status and by the physician's receipt of free vaccines. RESULTS: Of the 1769 physicians with whom an interviewer spoke, 1236 participated. Most respondents (66%) were likely to refer an uninsured child to the health department for vaccination, whereas only 8% were likely to refer a child who had insurance that covers vaccination. The majority (58%) of physicians reported differential referral based on insurance status. Among physicians who received free vaccine supplies from the VFC program or elsewhere, 44% were likely to refer an uninsured child whereas 90% of those not receiving free vaccine were likely to refer the same child (P<.001). In regression analysis, the receipt of free vaccine supplies accounted for 24% of the variance in the likelihood to refer an uninsured child for vaccination. CONCLUSIONS: Physicians receiving free vaccine supplies report being less likely to refer children to public clinics for vaccinations.

Correlates of oral contraceptive use in Italian women, 1991-93.

In order to understand the determinants of oral contraceptive (OC) use in Italy, we analyzed data on 1577 women aged under age 60 (median age 50 years) admitted as controls in a case-control study of breast cancer. Included in this group were women with acute, non-neoplastic, non-gynecologic, non-hormone-related diseases, admitted between 1991 and 1994 to a network of hospitals in six Italian centres. A total of 275 (17.4%) women reported ever OC use. Oral contraceptive use was strongly related to the level of education: in comparison with women reporting < 7 years of schooling, the multivariate odds ratios (OR) of ever OC use were 2.2 and 3.5, respectively, in women reporting 7-11 and > or = 12 years of schooling (chi 1(2) trend 40.87 p < 0.001). OC use was inversely related to body mass index (BMI): in comparison with leaner women (BMI, Kg/m2, < 25), the OR of being an ever OC user was 0.8 and 0.7, respectively, in women with BMI 25-< 30 and > or = 30 (chi 1(2) trend 3.36, p = 0.07). Parous women more frequently tended to be OC users than nulliparous ones, the estimated OR being 2.4 and 2.3, respectively, in women reporting 1 or 2 and 3 or more births in comparison with nulliparae. Likewise, women with history of induced abortions were more frequently ever OC users (OR for > or = 1 induced abortions vs no induced abortion, 1.8, 95% Cl 1.2-2.6). However, no relationship emerged between OC use and history of spontaneous abortions. Finally, there was no relation between pill use and history of hypertension, cholelithiasis, thyroid diseases, hyperlipidemia, family history of breast cancer, uterine fibroids and benign breast disease. Women with a history of diabetes were less likely to be OC users (OR 0.6), but the finding was not significant. The results of this analysis are comparable with those of a study conducted in the same population in the early 1980's, and suggest that sociodemographic and reproductive factors, rather than medical history, are major determinants of OC use in this population.

PIP: In order to understand the determinants of oral contraceptive (OC) use in Italy, data were analyzed on 1577 women under age 60 (median age 50 years) admitted as controls in a case-control study of breast cancer. Women were included with acute, non-neoplastic, non-gynecologic, non-hormone-related diseases, admitted between 1991 and 1994 to a network of hospitals in 6 Italian centers. A total of 275 (17.4%) women reported ever use of OCs. OC use was strongly related to the level of education: the multivariate odds ratios (OR) of ever use were 2.2 and 3.5, respectively, in women reporting 7-11 and or= 12 years of schooling (p 0.001) compared to women reporting 7 years of schooling. OC use was inversely related to body mass index (BMI): the OR of ever use was 0.8 and 0.7, respectively, in women with BMI 25 - 30 and or= 30 (p = 0.07) compared to leaner women (BMI, Kg/m2, 25). Parous women more frequently tended to be OC users than nulliparous ones, the estimated OR being 2.4 and 2.3, respectively, in women reporting 1 or 2-3 or more births in comparison with nulliparae. Likewise, women with a history of induced abortions were more frequently ever users (OR for or= 1 induced abortions vs. no induced abortion, 1.8, (95% CI 1.2-2.6). However, no relationship emerged between OC use and history of spontaneous abortions. Finally, there was no relation between pill use and history of hypertension, cholelithiasis, thyroid diseases, hyperlipidemia, family history of breast cancer, uterine fibroids and benign breast disease. Women with a history of diabetes were less likely to be OC users (OR 0.6), but the finding was not significant. The results of this analysis are comparable with those of a study conducted in the same population in the early 1980's, and suggest that sociodemographic and reproductive factors, rather than medical history, are major determinants of OC use in this population.

Funding resuscitation research.

The present trend in managed care has meant downsizing expectations concerning the availability of support for resuscitation research. This trend applies to funding possibilities from industry, governmental agencies, and nongovernmental agencies (Table 1). There will be increasing barriers to making innovations. Truth, science, and good patient care alone will not make potential donors give grants. Investigators must also understand the potential donors' expectations and be persuasive. "Delight your donor". Industries' concerns include intellectual property rights and publications. The National Institutes of Health, recently favoring molecular biology over lifesaving therapies or integrated physiologic research, is an anomaly. The current peer review system propagates itself without having advocates for resuscitation research. This system has become a self-fulfilling prophecy. The American Heart Association is only recently, after 30 yrs of educational activities concerning cardiopulmonary resuscitation, considering putting some basic research money into resuscitation research. In university hospitals, where clinical departments have made significant contributions to innovative, clinically relevant life-support research, funded with incomes from patient care, the sky is beginning to fall. Resuscitation researchers need persuasive advocates with clout and hard data to convince funding agencies to give support to multilevel research and development in areas of pathophysiology and reversibility of terminal states and clinical death--to give these topics a higher priority than is currently available.

Evaluation of outpatient geriatric assessment: a randomized multi-site trial.

OBJECTIVE: To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care. DESIGN: Randomized, controlled clinical trial, with 12-month follow-up. SETTING: Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices. PARTICIPANTS: 442 recruited older adults with a health problem or recent change in health status. INTERVENTION: Outpatient consultative geriatric assessment or usual physician assessment. MAIN OUTCOME MEASURES: Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being. RESULTS: Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group. CONCLUSIONS: Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.

Assessment of prehospital and hospital response in disaster.

The assessment of the response of a prehospital/hospital system to a disaster will prove a complex and challenging undertaking for those who attempt it. Data availability and quality will prove to be an immediate problem. Finding the time to devote to assessment is usually difficult. Identifying qualified and interested members of the required multidisciplinary team and, in particular, an individual with health services research background who can assist in all phases of the design and implementation of the project, is often difficult. Obviously, these problems will be less severe if they are addressed to some degree in the disaster plan. That is, a general protocol for assessment could be developed as part of the disaster planning effort and evaluation staff could tentatively be identified by position (e.g., emergency department medical director). The issue of data availability could be confronted and provisions made for the recording of at least minimal information on patient log forms under disaster conditions.

[Economic amputations of the lower limbs due to ischemia. I]. / Le demolizioni economiche degli arti inferiori per ischemia. Parte I.

The problem relating to leg amputation following ischemia are analysed in the first part of this study, bearing in mind that amputation must be as conservative as possible in order to ensure the best quality of life. Following a short review of the topic and the introduction of recent trends, the case for amputation, which must be early in order to be conservative, is studied. The first part of this article concludes with a discussion of Doppler and clinical evaluations as techniques used to determine the level of amputation.

[Economic amputations of the lower limbs due to ischemia. II]. / Le demolizioni economiche degli arti inferiori per ischemia. Parte II.

In this second note, some technical details used during amputation are described, leaving out the systematic description of interventions. The analysis of the postoperative period shows that the more distal the amputation, the higher the incidence of local complication, while about postoperative mortality our data show an opposite trend. The Authors conclude by pointing out that an early indication and an accurate evaluation often allow a more distal amputation, that must be as conservative as possible anyway.

Contacts with pharmacists before and after "free" medical care--the Quebec experience.

This study reports the effects which the introduction of a national health insurance plan had upon established patterns of seeking health advice from pharmacists. Data were obtained from a household survey conducted in Montreal, Canada before and after the introduction of the government sponsored compulsory health insurance program. The report documents the extent to which the citizens of Montreal sought advice about health matters from pharmacists and describes the dramatic alteration in the pattern of advice seeking which occurred when the economic barriers to medical care were removed.