"Voluntary" user fees in Buenos Aires hospitals: innovation or imposition?

Voluntary user fees in hospitals in Buenos Aires, which operate outside official controls, have not featured in other studies of health care in Argentina. After providing a historical overview of different hospital funding sources, the authors focus on the activity of cooperadoras--the organizations responsible for levying voluntary fees. Using detailed data from two case-study hospitals and more general financial sources, they assess the importance of these fees, identifying sharp variations between different hospitals, serious problems of under-reporting, and potential abuses. The authors also examine the means by which fees are levied and the degree of coercion involved. Voluntary fees are not a particularly successful funding strategy: the income they generate is variable; they are almost entirely unregulated; and they sometimes conflict with other, more legitimate funding sources. Most importantly, their voluntaristic aspect is largely notional: most patients are heavily pressured to make payments. The main motivation for continuing with voluntary fees is to avoid the political fallout that would probably result from introduction of a formal user fees policy.

Survey of respiratory sounds in infants.

BACKGROUND: Over the last decade there has been an apparent increase in childhood wheeze. We speculated that much of the reported increase may be attributed to the term wheeze being adopted by parents to describe a variety of other forms of noisy breathing. AIMS: To investigate terminology used by parents to describe their children's breath sounds. METHODS: An interview was carried out with the parents of 92 infants with noisy breathing, beginning with an open question and then directed towards a more detailed description. Finally, the parents were asked to choose from a wheeze, ruttle, and stridor on imitation by the investigator and video clips of children. RESULTS: Wheeze was the most commonly chosen word on initial questioning (59%). Only 36% were still using this term at the end of the interview, representing a decrease of one third, whereas the use of the word ruttles doubled. CONCLUSIONS: Our results reflect the degree of inaccuracy involved in the use of the term wheeze in clinical practice, which may be leading to over diagnosis. Imprecise use of this term has potentially important implications for therapy and clinical trials.

Reforming health insurance in Argentina and Chile.

The paper examines the recent reforms of health insurance in Chile and Argentina. These partially replace social health insurance with individual insurance administered through the private sector. In Chile, reforms in the early 1980s allowed private health insurance funds to compete for affiliates with the social health insurance system. In Argentina, reforms in the 1990s aim to open up the union-administered social insurance system to competition both internally and from private insurers. The paper outlines the specific articulation of social and individual health insurance produced by these reforms, and discusses the implications for health insurance coverage, inequalities in access to healthcare, and health expenditures.

Population ageing in developed and developing regions: implications for health policy.

Population ageing is now recognised as a global issue of increasing importance, and has many implications for health care and other areas of social policy. However, these issues remain relatively under-researched, particularly in poorer countries, and there is a dearth of specific policy initiatives at the international level. For example, the 1994 International Conference on Population and Development agreed to 15 key principles for future policy, but none of these even make indirect mention of the aged (International Conference on Population and Development, 1995, Documents. Programme of action of the 1994 International Conference on Population and Development. Population and Development Review, 21(2), 437-461). This paper seeks to highlight some of the key issues arising from population ageing. It begins with a brief overview of international trends in demographic ageing, and considers the health needs of different groups of older people. It sketches out some implications for policy, paying particular attention to the financing and organisation of health services. The final part of the paper contains a discussion about how older people have been affected by, and have adapted to, processes of social, economic and political change. Given the wide scope of these concerns, it is not possible to discuss any issue in detail, and the paper does not claim to give the subject matter a comprehensive or global treatment. It must be stressed that patterns of ageing and their implications for policy are highly complex and variable, and, as such, great care should be taken in generalising between the experiences of different groups of older people, and between different settings.

Old age, migration, and poverty in the shantytowns of Sao Paulo, Brazil.

PIP: This study examines the potential relationships between socioeconomic change, public policy, and the welfare of elderly people in Brazil. It focuses on one particular aspect of socioeconomic change: the flow of migrants from the countryside to the cities. Three interrelated aspects of older peoples¿ welfare were identified and examined in turn. These include their economic welfare and access to pensions, their access to health care, and their social status. In addition, a conceptual framework for the relationships is presented. Using microlevel research, the study finds that the outlined conceptual framework is of relevance to the experiences of poor elderly people living in shantytowns. Socioeconomic change and public policy had an important effect on older peoples¿ quality of life. It is also noted that rapid migration and the existence of formal pension programs had not undermined informal support for older people in poor urban areas, and family support was still the principal source of income. However, there were elements of the migration experience, such as its timing, that sometimes influenced the quality of life of older people. Further research as well as pilot projects addressing the needs of vulnerable individuals that are located in the poorest urban districts are recommended.^ieng

Screening for colorectal cancer in a high-risk population. Results of a mathematical model.

A mathematical model was used to estimate the cost-effectiveness of colorectal cancer screening strategies for people who are at high risk because of a first-degree relative with colorectal cancer. The model uses indirect evidence about such factors as cancer incidence, sensitivity and specificity of different tests, and treatment effectiveness. The analysis indicates that for screening people over 40 yr old an annual fecal occult blood test may reduce colorectal cancer mortality by about one-third, either colonoscopy or barium enema may reduce mortality by approximately 85%, a 3-5-yr frequency for endoscopies or barium enemas preserves 70%-90% of the effectiveness of an annual frequency, and beginning screening at age 50 reduces effectiveness by 5%-10%. Although both barium enemas and colonoscopies appear to be effective in reducing mortality, the lower cost of the barium enema makes it a more cost-effective strategy. All of these estimates depend on the baseline estimates of each of the factors incorporated in the model; the conclusions are most sensitive to assumptions about the natural history of adenomatous polyps, the bleeding of adenomas and presymptomatic cancers, and the sensitivity of the fecal occult blood test. Recommendations about colorectal cancer screening must also consider factors such as discomfort, inconvenience, and the availability of various technologies.

Gastric carcinogenesis induced by N-methyl-N'-nitro-N-nitrosoguanidine: role of gastrectomy and duodenal reflux.

The effect of gastrectomy and duodenal reflux on gastric carcinogenesis was studied because gastrectomized patients may be considered at "high risk" for the development of gastric stump cancer. Wistar rats received N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) (83 mg/liter) ad libitum in the drinking water for either four, eight, or twelve weeks. A control group received tap water. After MNNG administration animals were antrectomized. Antrectomy was not performed in a control group. Bowel continuity was restored either with a Billroth II (BIL) or with a ROUX en Y (ROUX) procedure. Duodenogastric reflux is possible after the BIL but not after the ROUX procedure. Eight months after the beginning of the experiment the stomachs of the animals were studied. In both operated and unoperated animals, the number of cancers observed was significantly related to the duration of MNNG administration. Animals receiving MNNG plus the BIL procedure had a significantly higher number of anastomotic cancers than the ROUX animals, indicating that duodenogastric reflux played a promotional role in gastric carcinogenesis. Three BIL gastrectomized rats not receiving the carcinogen had an adenocarcinoma on the anastomotic line further emphasizing the risk attached to the duodeno-gastric reflux.

Barrett's esophagus with adenocarcinoma in scleroderma.

The gastrointestinal manifestations of scleroderma are varied. Esophageal problems are common especially in patients with Raynaud's phenomenon. An adenocarcinoma complicating a Barrett's esophagus was identified in a patient with the CREST variant of scleroderma. The significance of this association and its relationship to chronic reflux esophagitis is discussed. Patients with scleroderma should be considered to be at an increased risk of developing this premalignant condition of the esophagus.

Nutrition and cancer.

Nutrition and cancer interact at several levels. Both dietary deficiencies and dietary excesses have been linked with changes in prevalence of certain human cancers. With respect to one particular nutrient, riboflavin, a dietary deficiency may decrease the development of spontaneous tumors in experimental animals but increase carcinogenesis due to certain agents. Cancer itself has profound effects upon nutritional status, and neoplastic tissue appears in general to resist dietary deficiency more effectively than normal tissues. Nutrition has a major role in therapy of cancer, but as an adjunct to the treatment plan rather than as an alternative. Parenteral nutrition, either peripheral or total, can provide support that is critically needed when patients cannot eat or swallow, have obstruction or malabsorption, or are otherwise unable to utilize dietary nutrients in adequate amounts. The advent of home parenteral nutrition now provides a means for long-term rehabilitation of cancer patients.

A morphologic and kinetic basis for the more invasive character of N-methyl-N'-nitro-N-nitrosoguanidine induced duodenal tumors following pyloroplasty.

Pyloroplasty increased the invasiveness of duodenal tumors in Wistar rats receiving N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) for 12 weeks (83 mg/l in drinking water) (Arch. Surg., 117, 768-771). To assess morphologic and kinetic alterations, analyses of tritiated thymidine (3HTdR) pulse-labeled fundic, antral and duodenal mucosa were carried out. The normal appearance of MNNG-treated antral and duodenal mucosa was characterized by the appearance of elongated hyperactive columns exhibiting elevated levels of DNA synthesis. Pyloroplasty in carcinogen-treated rats induced both a 3-fold enhancement in the number of these elongated columns and an elevation in the number of proliferating cells within them (P less than 0.001). In the MNNG and pyloroplasty treated duodenal mucosa 26% of columns contained over 130 cells/column rather than an average of 100 cells in normal appearing MNNG-treated mucosa. DNA synthesis was increased by 23% within these hyperactive glands (11.3 proliferative cells/column vs. 9.4/column in normal appearing mucosa). Pyloroplasty creates both an increase of gastric bile reflux and an increase of the gastric evacuation rate, conditions which influence cell proliferation. Such alterations in antro-pyloro-duodenal physiology contribute to the increased cellular activity observed, promote malignant transformation and foster the expression of invasiveness.

Tissue concentrations and proliferative effects of massive doses of ascorbic acid in the mouse.

The effect of ascorbic acid supplementation on CF1 mice fed ascorbic acid for approximately six months at dose levels of 1%, 5%, and 10% of diet was investigated by analysis of tissue ascorbic acid concentration in the liver, kidney, stomach, small intestine, and large bowel. The effect on epithelial cell proliferation was also examined in the small and large bowel but only at the 5% level. In the control animals, ascorbic acid concentration was lowest in the liver (0.406 +/- 0.07 mg/g) and highest in the small bowel (0.754 +/- 0.16 mg/g). Dietary intake of 5% and 10% ascorbic acid significantly elevated levels in the liver (0.741 +/- 0.13; p less than 0.05), and all doses of ascorbic acid significantly raised tissue concentrations in the kidney and colon. No difference was observed in the percentage of DNA-synthesizing cells in the jejunum of controls or animals fed 5% ascorbic acid at 1 or 24 hours after 3HTdR injection. However, at 1 hour a significantly decreased level of proliferation was observed in the distal colon of ascorbic-acid-treated mice compared with controls (labeling index [L.I.] = 7.3 +/- 0.28 vs. 10.1 +/- 1.15; p less than 0.05), and an even greater suppression of DNA synthesis was achieved by 24 hours (L.I. = 11.4 +/- 1.06 vs. 18.6 +/- 1.61; p less than 0.01). None of the doses of ascorbic acid employed was toxic to the experimental mice.

Surveillance for colorectal cancer in average-risk patients, familial high-risk groups, and patients with adenomas.

New concepts and technological advances have stimulated a heightened interest in the secondary prevention of colorectal cancer; the identification and eradication of premalignant lesions, and the detection of early cancer before the development of life-threatening consequences. This approach must be selective based on risk factors. Fecal occult blood testing and sigmoidoscopy have been applied to the average-risk patients, whereas x-rays, endoscopy, biopsy, and cytology have been applied to the high-risk groups for case findings and screening. Program results to date are encouraging for average-risk patients. Compliance with fecal occult blood testing and sigmoidoscopy has been high in motivated groups self-selected for entry into screening programs. The rate of positive slides, false-positivity, and predictive value for neoplasia has been acceptable. Dukes' staging of cancers has been favorable. False-negativity and mortality data are not yet available. Flexible sigmoidoscopy has been shown to be an effective substitute for rigid sigmoidoscopy in trained hands. Familial polyposis and Gardner's syndrome families have been well studied, but interest in the nonpolyposis inherited colon cancer families is relatively new. Followup procedures after polypectomy have been variable and only recently has there been an organized attempt to prospectively study the effectiveness of different followup plans. The National Polyp Study has been developed to address this issue.

Primary gastric lymphoma. A review of 50 cases.

The records of 50 patients with localized primary gastric lymphoma were reviewed and clinical and prognostic factors characterized. Pathologic material was reclassified according to Rappaport's, Lukes-Collins, and Lennert's Kiel classifications. Factors with the greatest prognostic significance included initial stage as determined by surgery and pathology, absolute tumor size, degree of penetration through the stomach wall, and histologic grade of the lymphoma. After surgical resection for cure, the overall 5-year disease-free survival was 47%. For stage I disease, this was 78% vs 29% for stage II (P = 0.006). Patients with lymphomas less than 5 cm in diameter had 58% 5-year disease-free survival vs 32% for those with tumors greater than 10 cm (P = 0.06). Full-thickness penetration decreased 5-year survival from 75% to 38% (P = 0.06). Patients with histologically low-grade lymphomas had a better prognosis than those with high-grade lymphomas. The most significant correlation of histology to survival was seen with the Kiel classification with a 5-year survival of 39% for centroblastic polymorphous lymphoma vs 66% for LP immunocytoma. When lymphoma recurred it developed outside the abdomen in a majority of patients. The addition of abdominal radiation therapy to surgical resection made no significant impact on survival for either stage I or II disease.