Treatment, outcomes and costs of asthma exacerbations in Chilean children: a prospective multicenter observational study.

OBJECTIVE: To describe potential regional variations in therapies for severe asthma exacerbations in Chilean children and estimate the associated health expenditures. METHODS: Observational prospective cohort study in 14 hospitals over a one-year period. Children five years of age or older were eligible for inclusion. Days with oxygen supply and pharmacological treatments received were recorded from the clinical chart. A basic asthma hospitalization basket was defined in order to estimate the average hospitalization cost for a single patient. Six months after discharge, new visits to the Emergency Room (ER), use of systemic corticosteroids and adherence to the controller treatment were evaluated. RESULTS: 396 patients were enrolled. Patients from the public health system and from the north zone received significantly more days of oxygen, systemic corticosteroids and antibiotics. Great heterogeneity in antibiotic use among the participating hospitals was found, from 0 to 92.3% (ICC 0.34, 95% CI 0.16-0.52). The use of aminophylline, magnesium sulfate and ketamine varied from 0 to 36.4% between the different Pediatric Intensive Care Units (ICC 0.353, 95% CI 0.010-0.608). The average cost per inpatient was of $1910 USD. 290 patients (73.2%) completed the follow-up six months after discharge. 76 patients (26.2%) were not receiving any controller treatment and nearly a fourth had new ER visits and use of systemic corticosteroids due to new asthma exacerbations. CONCLUSIONS: Considerable practice variation in asthma exacerbations treatment was found among the participating hospitals, highlighting the poor outcome of many patients after hospital discharge, with an important health cost.

Creation of a gilded trap by the high economic value of the Maine lobster fishery.

Unsustainable fishing simplifies food chains and, as with aquaculture, can result in reliance on a few economically valuable species. This lack of diversity may increase risks of ecological and economic disruptions. Centuries of intense fishing have extirpated most apex predators in the Gulf of Maine (United States and Canada), effectively creating an American lobster (Homarus americanus) monoculture. Over the past 20 years, the economic diversity of marine resources harvested in Maine has declined by almost 70%. Today, over 80% of the value of Maine's fish and seafood landings is from highly abundant lobsters. Inflation-corrected income from lobsters in Maine has steadily increased by nearly 400% since 1985. Fisheries managers, policy makers, and fishers view this as a success. However, such lucrative monocultures increase the social and ecological consequences of future declines in lobsters. In southern New England, disease and stresses related to increases in ocean temperature resulted in more than a 70% decline in lobster abundance, prompting managers to propose closing that fishery. A similar collapse in Maine could fundamentally disrupt the social and economic foundation of its coast. We suggest the current success of Maine's lobster fishery is a gilded trap. Gilded traps are a type of social trap in which collective actions resulting from economically attractive opportunities outweigh concerns over associated social and ecological risks or consequences. Large financial gain creates a strong reinforcing feedback that deepens the trap. Avoiding or escaping gilded traps requires managing for increased biological and economic diversity. This is difficult to do prior to a crisis while financial incentives for maintaining the status quo are large. The long-term challenge is to shift fisheries management away from single species toward integrated social-ecological approaches that diversify local ecosystems, societies, and economies.

Low back pain in Australian adults: the economic burden.

This paper reports the results of a "cost-of-illness" study of low back pain (LBP) in Australian adults. It estimates the direct cost of LBP in 2001 to be AU dollars 1.02 billion. Approximately 71% of this amount is for treatment by chiropractors, general practitioners, massage therapists, physiotherapists and acupuncturists. However, the direct costs are minor compared to the indirect costs of AU dollars 8.15 billion giving a total cost of AU dollars 9.17 billion. LBP in Australian adults represents a massive health problem with a significant economic burden. This burden is so great that it has compelling and urgent ramifications for health policy, planning and research. This study identifies that research should concentrate on both direct but particularly the indirect costs including cost-effective management regimes that encourage an early return to duties.

Ecology. The value of nature and the nature of value.

Ecosystems are capital assets: When properly managed, they yield a flow of vital goods and services. Relative to other forms of capital, however, ecosystems are poorly understood, scarcely monitored, and--in many important cases--undergoing rapid degradation. The process of economic valuation could greatly improve stewardship. This potential is now being realized with innovative financial instruments and institutional arrangements.

Preliminary assessment of whole-blood, red-cell and platelet- leucodepleting filters for possible induction of prion release by leucocyte fragmentation during room temperature processing.

Universal leucodepletion is being introduced in the U.K. to reduce a theoretical risk of Creutzfeldt-Jakob disease (CJD) transmission. If CJD infectivity is associated with leucocytes, any cell fragmentation associated with filtration could reduce the potential benefit. Four types each of whole blood, red cell and platelet leucodepletion filters were assessed after holding of blood units for at least 4 h at 22 degrees C. In all cases the mean residual leucocyte content was <1 000 000 per unit, with only two individual filtered whole blood units having a leucocyte content exceeding this. Evidence of leucocyte fragmentation during filtration was sought but not found by assay of soluble elastase, beta-thromboglobulin and normal prion protein, as well as by isotopic labelling of leucocyte external membrane. These preliminary studies indicate that it was possible to prepare leucodepleted blood components by filtration at room temperature, and that this appeared not to be associated with overt cell fragmentation. Definitive demonstration that fragmentation does not occur requires the development of improved general (non-specific) assays for cell membrane fragments.

Christianity, development, and women's liberation.

PIP: This paper explores the relationship between Christianity, development, and women's liberation. The article examines the opportunities and constraints, which exist for women in the tradition of mainstream Christianity regarding their sexuality and family life. These concepts were investigated within the community level, the church itself, convent life, in the economy, and at wider national and international levels. Subordination of women through religion is the result of imposing social codes regarding women's roles, behavior, and relationships with men. However, equality can be achieved if the forms and substance of religious practice is reexamined and changed with liberation of women in mind. There is also a need to address the cultural and spiritual imperialism brought about by religion.^ieng

Self-care and breast cancer recovery.

PURPOSE: This study identified self-care behaviors used by women during and after radiation therapy for early-stage breast cancer. DESCRIPTION OF STUDY: Interviews with 23 women 7 months post-radiation therapy for breast cancer were analyzed for descriptions of self-care. The interviews were part of the final data collection in a longitudinal study investigating experiences post-treatment. RESULTS: Self-care behaviors reported most frequently were establishing a good support network, living life to the fullest despite illness, regulating feelings, managing stress, and taking responsibility for one's own health. Results suggest that breast cancer patients have many needs that continue to require attention post-radiation therapy, making self-care an important consideration throughout recovery. CLINICAL IMPLICATIONS: Quality of self-care may make a significant difference to women after treatment for breast cancer. Healthcare providers can promote self-care by encouraging patients to conserve energy, to engage in relationships, and to maintain a positive outlook and by suggesting activities that help patients cope, adapt, and manage symptoms during and after treatment.

Public health in a managed care environment.

As the health care system moves in a new direction, toward managed care, the critical role of public health in society's efforts to mitigate illness and the realization of health become more apparent. Indeed, the public health problems of this era will not yield to simple solutions. They require a multitude of resources, both human and material, and a myriad of services derived from these resources. Public health's role is to serve as the government's presence in assessing health status, developing policy, evaluating the effectiveness of policy implementation, and assuring access to and quality of comprehensive health services. Increasingly, public health must coordinate a wide array of systems in both the private and public sectors to fulfill its purpose.

Cancer risk assessment.

Increasing efforts to reduce the burden of cancer have brought into sharp relief the relevance of cancer risk assessment in preventing the occurrence and, when that is not possible, preventing the progression of the disease. Methods for estimating human cancer risk have evolved steadily over the past few decades as more has been learned about molecular, genetic, and biological aspects of cancer. These methods have been applied with increasing frequency in community-based approaches to reduce the risk of environmentally provoked cancers. At the same time, patients are showing increased interest in estimates of their likelihood of developing cancer during the next 10, 20, or 30 years. This interest is involving more physicians in human cancer risk assessment in clinical counseling settings.

Causes of admission of African patients to Gelukspan Hospital, North West Province, South Africa.

An enquiry has been made into the causes of admission in 1994 of African patients to Gelukspan Hospital, North West Province, South Africa. The study concerned 3791 patients of whom 3533 (93.2%) were classifiable. Two groups were not included in this number, namely, 1584 'lodgers' (e.g. mothers of infants), and 1868 females admitted for normal pregnancy. Of the 3533 patients, 940 (26.6%) were aged 14 years and younger; 545 (58.0%) these were boys and 395 (42.0%) were girls. The main causes of their admission were pneumonia, gastroenteritis, trauma, poisoning, and infections. Of the 2593 adults, 1418 (54.7%) were males and 1175 (45.3%) females. Among males, chief causes were pulmonary tuberculosis, trauma and accidents, congestive cardiac failure, psychosis, cancer and diabetes. Of the females, chief causes were pulmonary tuberculosis, trauma and accidents, pregnancy related disorders, gastroenteritis, anaemia and pneumonia. Regarding other diseases, 4.5% of adults were admitted for cancer, and 1.8% for diabetes. The general pattern of admissions is similar to that reported in other rural hospitals. The causes of admissions are discussed, regarding; (i) public health improvements occurring, and (ii) means of promoting further improvements by community self-help, and by help from State health and other services.

The hand that rocks the cradle should also rock the boat.

PIP: The Gender and Development Unit (GADU) was established in 1985 at Oxfam. The unit challenged previous development assumptions; gender analysis required recognition of inequalities based on class, caste, age, and education, as well as on gender. Personal attitudes and professional actions were scrutinized, views on how to achieve gender equity differed, and accusations of cultural imperialism were made. Currently, the organization has a gender policy that is implemented by managers; the "feminist thought police" are gone. Consolidation should occur under a new team. However, questions remain concerning organizational culture; gender roles and relations are culturally determined and culture-specific. There is great diversity in this regard within Oxfam. Some field offices have "family-friendly" policies and procedures, but the "glass ceiling," albeit higher, still exists for women. The ability to read, write, and respond quickly are valued by the work culture, and there is little time to reflect. Discursive expression is unwelcome in the presence of information overload. Both men and women are now making childcare arrangements, and one of the first items on the agenda of the GADU was a workplace nursery. Its establishment came about from "corporate management recognizing the need to look at process as well as product, and from field offices shaping their work cultures to their values." The struggle for gender equality has only changed its form.^ieng

Assessment of urinary gonadotropin in solid carcinomas other than gynecological tumors.

To the already long list of existing tumor markers, a new marker has been recently added, the urinary gonadotropin peptide (UGP). This marker is determined in the urine of cancer patients and is considered to be particularly specific for ovarian carcinomas. The purpose of our study was to assess the specificity of UGP in a variety of malignancies other than ovarian carcinomas, e.g., breast, colonic, lung, and urogenital tumors (n = 50 each). The tumors were compared with benign lesions of the same organs. Urine samples of 50 healthy donors served as controls. The 450 urine samples were tested in duplicate using the UGP EIA-kit from Ciba Corning Diagnostics. All tumors were staged and histologically classified. For normalization in all samples, creatinine levels were determined. UGP was found in all tested tumors, however, with very low sensitivity of 20% in urogenital tumors, 46% in lung, and 30% or 27% in colon and breast carcinomas, respectively. The specificity of UGP was comprised between 100% (breast) and 88%. Clearly elevated UGP-concentrations were seen in postmenopausal women. A comparison of UGP with the optimal markers for each tumor system showed that UGP is not superior to these markers. However, we can confirm UGP as being an optimal marker for gynecological carcinomas.

Psychosocial needs of family caregivers of terminally ill patients.

The primary caregivers (mean age = 63 yr.) of 28 terminally ill veterans (mean age = 67 yr.) who were living at home were surveyed for their concrete and psychosocial needs. The caregivers also completed the Beck Depression Inventory, the Life Satisfaction Index, the Provision of Social Relations scale, and the Burden Inventory. The rank order of concrete and psychosocial needs is reported for these caregivers. Increased scores on depression were associated with decreased life satisfaction as was low social support. Not surprisingly, higher numbers of concrete and psychosocial needs were associated with increases in depression.

Editorial.

PIP: This editorial introduces an issue of Focus on Gender that explores some of the dilemmas facing emergency relief programs and records the particular experiences of women in crisis situations. The editorial opens by noting that, while it is now widely recognized that gender considerations are essential to development programs, many funders and agencies consider gender considerations irrelevant or optional to the disaster relief efforts that occupy an increasingly large portion of the development agenda. Factors that create a false dichotomy between development and relief efforts include the sudden visibility of the impact of disasters and the requirement for swift responses. Relief efforts also involve different funding and complex logistics. A prevailing theme of the papers in this issue is the need to consider relief and development as parts of the same process. Various papers point to the vital importance of understanding gender relations in times of disaster so that relief workers avoid the mistake of handing over women's traditional responsibilities to men and removing all traditional power held by women. Efforts must be made to understand the impact of disaster on women's reproductive and productive roles. Articles, therefore, explore how important it is to remember women's long-term and strategic interests, to make efforts to reduce violence against women, to meet women's health needs, and to consider women as a resource rather than a burden. The papers show that action taken during disasters can deepen existing gender inequalities or foster positive changes by enhancing rather than diminishing women's position.^ieng