Advancing Health Security and Disease Eradication Through Peace and Health: A Mali Case Study.

Conflict and violence constitute threats to public health. As levels of conflict increase within and between countries, it is important to explore how conflict resolution initiatives can be adapted to meet the health needs of communities, and how addressing the health needs of communities can assist in conflict resolution and contribute to health security. In conflict-affected central Mali, a Peace through Health Initiative, piloted between 2018 and 2022, used conflict resolution trainings, facilitated community meetings, and human and animal health interventions to negotiate "periods of tranquility" to achieve public health goals. Project activities resulted in improved health, improved livelihoods, reduced violence, improved trust among stakeholders, and greater inclusion of community members in peace and health decisionmaking. The Peace-Health Initiative generated several lessons learned related to 3 phases of peace-health programming: preintervention, program development, and implementation. These lessons can be applied to support expanded Peace through Health Initiatives within Mali, may be adaptable to other conflict-afflicted contexts, and should be considered in relation to the implementation of global health security.

The effect of multiple firings on the marginal integrity of pressable ceramic single crowns.

STATEMENT OF PROBLEM: The marginal adaptation of metal ceramic crowns is affected by firing cycles for veneering porcelain application. The effect of multiple firings on the marginal integrity of pressable ceramic core crowns is unknown. PURPOSE: The purpose of this in vitro study was to evaluate the effect of repeated firing cycles on the marginal discrepancy of veneered (layered) pressable ceramic anterior crowns with 2 different finish line configurations. MATERIAL AND METHODS: Forty pressable ceramic single anterior complete crowns were fabricated from 2 systems (IPS Empress Esthetic and IPS e.max Press) with 2 finish line designs (shoulder, chamfer) on epoxy resin dies. Specimens were divided into 4 groups of 10, and measurements were made after pressing (control) and after 5 veneer firing stages: 1) wash, 2) first incisal, 3) second incisal, 4) characterization and glazing, and 5) corrective. The change in vertical marginal discrepancy was measured with a light microscope at 4 locations: facial (F), mesial (M), lingual (L), and distal (D) surfaces. One-way ANOVA (α-=.05) was used to evaluate the marginal change. A Student-Newman-Keuls test was also used for comparison among the groups. RESULTS: There were no significant changes in the vertical marginal integrity related to ceramic type and marginal location and their interactions. However, there was a significant marginal integrity change during the characterization and glazing firing stage. (P<.05) CONCLUSIONS: The marginal gap increased for both systems during veneer application and decreased during the characterization and glazing firing cycle. The total marginal fit change after 5 firings was 0.33 µm for IPS e.max Press, and 0.27 µm for IPS Empress Esthetic.

The social cost of adverse medical events, and what we can do about it.

Adverse medical events-medical interventions that cause harm or injury to a patient separate from the underlying medical condition-are unfortunately an all-too-frequent occurrence in US hospitals. They may cause as many as 187,000 deaths in hospitals each year, and 6.1 million injuries, both in and out of hospitals. We estimate the annual social cost of these adverse medical events based on what people are willing to pay to avoid such risks in non-health care settings. That social cost ranges from $393 billion to $958 billion, amounts equivalent to 18 percent and 45 percent of total US health care spending in 2006. A possible solution: Patients offered voluntary, no-fault insurance prior to treatment or surgery would be compensated if they suffered an adverse event-regardless of the cause of their misfortune-and providers would have economic incentives to reduce the number of such events.

Employer-sponsored, personal, and portable health insurance.

Personal and portable health insurance is an idea whose time has come. Despite its stated intent, however, the Health Insurance Portability and Accountability Act (HIPAA) strongly discourages individually owned, portable insurance. Federal tax laws do the same. Some examples of portable benefits exist, such as the TIAA-CREF system. This paper considers three reform models for moving toward personal, portable coverage: the National Center for Policy Analysis-Texas Blue Cross Blue Shield proposal, the Massachusetts health care plan, and a health reimbursement arrangement (HRA) approach. Congress could make the transition smoother by clarifying when and if individually owned insurance can be purchased with pretax dollars.

What is consumer-directed health care?

To control health care costs, someone must choose between health care and other uses of money. The value of most health care is experienced subjectively, as is the value of other goods and services. No one is in a better position to make these subjective trade-offs than patients themselves. The current system not only systematically denies patients the opportunity to make such choices, it distorts the incentives of providers in the process. Chronic patients in particular would be much better off if they could manage more of their own health care dollars and if providers were free to compete to meet their needs.

Solving the problem of the uninsured.

Reform of the United States health care system is less complicated than at first might appear. The building blocks of an ideal system are already in place. The federal government already generously subsidizes private health insurance and safety net care. What is wrong with the current system is that there are too many perverse incentives. One could reasonably argue that government is doing more harm than good, and that a laissez faire policy is better than what is now in place. Nonetheless, if government is going to be involved in a major way in the health care system, perverse incentives should be replaced with neutral ones. At a minimum, government policy should be neutral between private insurance and the social safety net, never spending more on free care for the uninsured than it spends to encourage the purchase of private insurance. Careful application of this principle would go a long way toward creating an ideal health care system.

Pain in hospitalized pediatric patients: how are we doing?

OBJECTIVE: The purpose of this study was to provide a baseline description of the prevalence of pain and pain management strategies in a pediatric hospital and to compare the prevalence of pain in this hospital to that in published reports in the literature. METHODS: Two hundred thirty-seven children ranging in age from 10 days to 17 years and 223 parents participated in an 8-hour survey on 5 inpatient units. Information about pain intensity and pain affect was collected from the children older than 6 years of age and from parents of those who were younger at 4 2-hour intervals. Information about procedural pain was collected from children, parents, and health care professionals over this 8-hour period. The type and amount of analgesia were also noted. RESULTS: More than 20% of the children had clinically significant pain at each of the 2-hour intervals, and 7 had pain scores of 5/10 or greater for the majority of the study day. At least 50% of the children were found to be pain-free during the 4 intervals, and there was a high level of agreement between parents and children's pain-intensity ratings. One hundred fifty-seven children had medication ordered and 80 children had no analgesia ordered. There was no significant correlation between characteristics of the patients and amounts or types of medication given. No analgesia was administered via intramuscular or subcutaneous injection. DISCUSSION: Although these results are encouraging in that a significant portion of the children were pain-free during the study day, the number of children who had clinically significant pain was too high. The results of this study compare with others in that a significant number of children were inadequately treated for pain. Clinical implications are discussed.

The role of parent training in treatment of preschoolers with ADDH.

The efficacy of group parent training was assessed in improving compliance and time on task in preschoolers with attention-deficit disorder with hyperactivity. Positive effects were obtained on measures of child compliance, but not on measures of attention. Parental compliance-management skills and overall style of interaction were also positively affected. The use of parent training for early intervention with ADDH children is discussed.

The efficacy and efficiency of a self-administered treatment for adolescent migraine.

Migraine headaches are frequent in adolescents. Although many adolescents are adequately treated palliatively with analgesics, an important subgroup requires prophylactic treatment. Medical treatments for adolescents with frequent severe headaches is often problematic. Prophylactic pharmacological treatments are often shunned by adolescents and their parents because of concern over drug usage. Moreover, propranolol, the most widely used prophylactic drug with adults, is frequently not effective. Psychological interventions are effective but are costly and often not available. A randomized controlled trial was undertaken to evaluate the efficacy and efficiency of a predominantly self-administered treatment that could be delivered in a very cost-efficient format. Eighty seven adolescents (63 females and 24 males) ranging in age from 11 to 18 years were randomly assigned to receive a self-administered treatment, the same treatment delivered by a therapist or a control treatment. Self-administered and clinic treatment were equally effective and superior to the control treatment. However, the self-administered treatment was substantially more efficient. Both active treatments were durable at 1-year follow-up.

Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity.

Despite the early onset of attention deficit disorder with hyperactivity (ADDH), there is a dearth of treatment studies with preschoolers with this disorder. Forty-six families with ADDH preschoolers were randomly assigned to either an immediate or a delayed group parent training program aimed at improving child compliance. Groups were balanced on demographic variables. Treatment outcome was evaluated by comparing the groups at pre- and posttreatment and 3-month follow-up on measures of parent-child interactions during free play, a compliance task, and parent-supervised activities, as well as on parent-completed Conners Hyperkinesis Index scores. Positive treatment effect was obtained on measures of compliance, parental style of interaction, and management skills. These improvements were maintained at 3-month follow-up. Evaluation of treatment effects on nontargeted child behaviors indicated no generalization.

Attention and impulsivity characteristics of the biological and adoptive parents of hyperactive and normal control children.

On tests comparing 176 biological and adoptive parents of hyperactive and normal control children, biological parents of hyperactives evidenced more attentional difficulties, slower mean reaction times, and fewer correct recognitions than did the other parents. They showed no significant differences in impulsivity. A familial association between childhood hyperactivity and attentional deficits in the biological parents was suggested, as was the persistence of attentional difficulties as compared to impulse control problems.

Cognitive and relaxation treatment of paediatric migraine.

The present study compared the efficacy of two active treatments, relaxation training and cognitive coping, with a non-specific placebo control in the treatment of 42 children and adolescents with migraine. The first treatment is a simplified version of progressive deep muscle relaxation; the second, a form of cognitive restructuring involving the alteration of dysfunctional thought processes. The results demonstrated that each active treatment was superior to the non-specific intervention in reducing overall headache activity and frequency but not duration or intensity. There were no differences between the experimental groups, and both continued to improve through a 16-week follow-up period, but the control group did not. Initial level of headache severity was an important factor in treatment outcome, with children with severe headaches responding better than those with milder headaches. Possible reasons for the differential treatment effects are discussed, and the implications for future research are considered.

Vicissitudes of follow-up studies: differential effects of parent training and stimulant medication with hyperactives.

A two-year outcome study of 73 hyperactive children supports both previous short-term studies which suggested that stimulant medication is superior to parent training and long-term studies which found no differences between the two interventions. The discrepancy is discussed in light of complications that inevitably arise in outcome studies and that tend to preclude meaningful outcomes in long-term studies. The development of new research strategies is called for.