Competition and quality indicators in the health care sector: empirical evidence from the Dutch hospital sector.

There is much debate about the effect of competition in healthcare and especially the effect of competition on the quality of healthcare, although empirical evidence on this subject is mixed. The Netherlands provides an interesting case in this debate. The Dutch system could be characterized as a system involving managed competition and mandatory healthcare insurance. Information about the quality of care provided by hospitals has been publicly available since 2008. In this paper, we evaluate the relationship between quality scores for three diagnosis groups and the market power indicators of hospitals. We estimate the impact of competition on quality in an environment of liberalized pricing. For this research, we used unique price and production data relating to three diagnosis groups (cataract, adenoid and tonsils, bladder tumor) produced by Dutch hospitals in the period 2008-2011. We also used the quality indicators relating to these diagnosis groups. We reveal a negative relationship between market share and quality score for two of the three diagnosis groups studied, meaning that hospitals in competitive markets have better quality scores than those in concentrated markets. We therefore conclude that more competition is associated with higher quality scores.

Ileal perforation caused by cytomegalovirus infection in an immunocompetent adult.

A 71-year-old woman developed a small bowel perforation due to cytomegalovirus infection. She did not taken any immunosuppressive medication and her cellular immunity was normal. Surgical resection and antiviral therapy with ganciclovir led to complete recovery. As far as we know, this paper reports the first case of small bowel perforation due to cytomegalovirus infection in a non-immunocompromised patient. Nevertheless the patient was known with diabetes mellitus. It should be emphasised that elderly patients have impaired immune defences and may be unsuspected hosts of opportunistic infections.

Microscopic colitis with giant cells.

AIMS: Collagenous colitis and lymphocytic colitis are the two types of microscopic colitis with specific morphological features. In this report we describe a new histopathological subtype of microscopic colitis. METHODS AND RESULTS: Colonoscopy in four patients with chronic watery diarrhoea showed no macroscopic abnormalities. The random biopsies from the colon showed subepithelial multinucleated giant cells in combination with the features of collagenous colitis in three patients and lymphocytic colitis in one patient. These multinucleated giant cells were positive for CD68. The density of macrophages was highest in the most superficial part of the lamina propria. In one patient, a previous biopsy showed features consistent with collagenous colitis without multinucleated giant cells. Treatment with budesonide led to the disappearance of diarrhoea in all four patients. CONCLUSIONS: The clinical and histopathological features of the four presented patients indicate that there exists a histopathological subtype of microscopic colitis characterized by the presence of subepithelial multinucleated giant cells, which probably arise from fusion of subepithelial macrophages. Analysis of more patients with this histopathological subtype of microscopic colitis is necessary to determine whether they also form a clinically distinct group.

Production of the isoflavones genistein and daidzein in non-legume dicot and monocot tissues.

Metabolic engineering for production of isoflavones in non-legume plants may provide the health benefits of these phytoestrogens from consumption of more widely used grains. In legumes, isoflavones function in both the symbiotic relationship with rhizobial bacteria and the plant defense response. Expression of a soybean isoflavone synthase (IFS) gene in Arabidopsis plants was previously shown to result in the synthesis and accumulation of the isoflavone genistein in leaf and stem tissue (Jung et al., 2000). Here we further investigate the ability of the heterologous IFS enzyme to interact with the endogenous phenylpropanoid pathway, which provides the substrate for IFS, and produces genistein in several plant tissue systems. In tobacco (Nicotiana tabacum) floral tissue that synthesizes anthocyanins, genistein production was increased relative to leaves. Induction of the flavonoid/anthocyanin branch of the phenylpropanoid pathway through UV-B treatment also enhanced genistein production in Arabidopsis. In a monocot cell system, introduced expression of a transcription factor regulating genes of the anthocyanin pathway was effective in conferring the ability to produce genistein in the presence of the IFS gene. Introduction of a third gene, chalcone reductase, provided the ability to synthesize an additional substrate of IFS resulting in production of the isoflavone daidzein in this system. The genistein produced in tobacco, Arabidopsis, and maize (Zea mays) cells was present in conjugated forms, indicating that endogenous enzymes were capable of recognizing genistein as a substrate. This study provides insight into requirements for metabolic engineering for isoflavone production in non-legume dicot and monocot tissues.