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1.
Eur J Nucl Med Mol Imaging ; 49(13): 4478-4489, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35831715

RESUMO

BACKGROUND: In patients with mild cognitive impairment (MCI), enhanced cerebral amyloid-ß plaque burden is a high-risk factor to develop dementia with Alzheimer's disease (AD). Not all patients have immediate access to the assessment of amyloid status (A-status) via gold standard methods. It may therefore be of interest to find suitable biomarkers to preselect patients benefitting most from additional workup of the A-status. In this study, we propose a machine learning-based gatekeeping system for the prediction of A-status on the grounds of pre-existing information on APOE-genotype 18F-FDG PET, age, and sex. METHODS: Three hundred and forty-two MCI patients were used to train different machine learning classifiers to predict A-status majority classes among APOE-ε4 non-carriers (APOE4-nc; majority class: amyloid negative (Aß-)) and carriers (APOE4-c; majority class: amyloid positive (Aß +)) from 18F-FDG-PET, age, and sex. Classifiers were tested on two different datasets. Finally, frequencies of progression to dementia were compared between gold standard and predicted A-status. RESULTS: Aß- in APOE4-nc and Aß + in APOE4-c were predicted with a precision of 87% and a recall of 79% and 51%, respectively. Predicted A-status and gold standard A-status were at least equally indicative of risk of progression to dementia. CONCLUSION: We developed an algorithm allowing approximation of A-status in MCI with good reliability using APOE-genotype, 18F-FDG PET, age, and sex information. The algorithm could enable better estimation of individual risk for developing AD based on existing biomarker information, and support efficient selection of patients who would benefit most from further etiological clarification. Further potential utility in clinical routine and clinical trials is discussed.


Assuntos
Doença de Alzheimer , Amiloidose , Disfunção Cognitiva , Humanos , Apolipoproteína E4/genética , Fluordesoxiglucose F18 , Reprodutibilidade dos Testes , Controle de Acesso , Tomografia por Emissão de Pósitrons , Disfunção Cognitiva/diagnóstico por imagem , Peptídeos beta-Amiloides , Doença de Alzheimer/diagnóstico por imagem , Doença de Alzheimer/genética , Amiloide , Biomarcadores
2.
Elife ; 112022 06 20.
Artigo em Inglês | MEDLINE | ID: mdl-35723428

RESUMO

New findings cast doubt on whether suppressing the RNA-binding protein PTBP1 can force astrocytes to become dopaminergic neurons.


Assuntos
Astrócitos , Controle de Acesso , Astrócitos/metabolismo , Células Cultivadas , Neurônios Dopaminérgicos/metabolismo
3.
Can J Psychiatry ; 67(11): 828-830, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35603661

RESUMO

Gatekeeping refers to clinicians' strict application of eligibility criteria to determine a trans patient's "fitness" to engage in medical transition, resulting in significant barriers to gender-affirming care. Gatekeeping often uses "mental readiness" as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination. Changing international trans health guidelines (the new World Professional Association for Transgender Health Standards of Care version 8) recommends clinicians shift from a gatekeeping model towards an informed consent model, which improves access to care. This commentary offers recommendations on how clinicians can reconsider existing "mental readiness" frameworks around medical transition to facilitate improved access to care.


Assuntos
Controle de Acesso , Pessoas Transgênero , Atenção à Saúde , Humanos , Consentimento Livre e Esclarecido
4.
Vaccine ; 40(16): 2462-2469, 2022 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-35307233

RESUMO

BACKGROUND: Multiplicity issues are increasingly common in vaccine clinical studies. Common causes include multi-valent combinations/co-administrations requiring separate evaluation of each antigen; numerous efficacy endpoints; requests from regulatory authorities for inclusion of specific powered endpoints into registration studies; interim analyses to support early decision-making. In a Phase III study to evaluate safety and immunogenicity of the 4-component Neisseria meningitidis serogroup B vaccine (4CMenB) when co-administered with 13-valent pneumococcal conjugate vaccine (PCV13) to healthy infants, a total of 49 statistical hypotheses were identified for the primary objectives as requested by the health authority. We designed a sequential testing strategy with visualization using a graphical gatekeeping procedure. METHODS: The 49 immunogenicity objectives related to evaluation of the sufficiency of the 4CMenB immune response; and demonstration of non-inferiority of PCV13 and 4CMenB when co-administered versus administration alone. We used a graphical shortcut display for closed families assuming that the multiple testing procedure is consonant and hypotheses that are rejected by a closed testing procedure are also rejected within the graphical short-cut. The 49 hypotheses were grouped into 10 families and distributed over 4 sequential steps following the clinical and statistical logical relationships agreed with the clinical team. Test decisions within the first 8 families will be made based on p-values with alpha propagation to subsequent families according to the tree structure. RESULTS: This tailored strategy allowed evaluation of all 49 statistical hypotheses individually, and more efficiently. The method avoided a rigid all-or-nothing approach whereby all endpoints fail if one or more null hypotheses cannot be rejected. Clinical input and agreement are critical for designing an efficient and fit-for-purpose strategy. Our experience could encourage more application of such strategies in increasingly complex clinical trials.


Assuntos
Infecções Meningocócicas , Vacinas Meningocócicas , Neisseria meningitidis Sorogrupo B , Ensaios Clínicos Fase III como Assunto , Controle de Acesso , Humanos , Lactente , Infecções Meningocócicas/prevenção & controle , Vacinas Pneumocócicas
5.
Death Stud ; 46(9): 2247-2255, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-33983869

RESUMO

No research has explored the potential of homeless youth to serve as gatekeepers for suicide prevention purposes. This study described and examined associations between gatekeeping beliefs (i.e. preparedness and efficacy), intent-to-intervene, and gatekeeping behaviors (approach/referral behavior). In a sample of 139 homeless youth (aged 14-24), regression analysis was used to characterize associations between gatekeeper beliefs, intent, and behaviors. On average, participants engaged in gatekeeper behaviors with 1-2 people over the past 3 months. Gatekeeping beliefs and intent were positively associated with behaviors. Gatekeeper training that targets these attributes is a promising prevention strategy for homeless youth, but may require population-specific adaptation.


Assuntos
Jovens em Situação de Rua , Suicídio , Adolescente , Controle de Acesso , Humanos , Intenção , Suicídio/prevenção & controle
6.
Fam Pract ; 39(1): 125-129, 2022 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-34173654

RESUMO

BACKGROUND: Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. OBJECTIVE: To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'. METHODS: A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. RESULTS: The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities. CONCLUSION: Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.


Assuntos
Controle de Acesso , Clínicos Gerais , Atitude do Pessoal de Saúde , Grupos Focais , Humanos , Relações Médico-Paciente , Pesquisa Qualitativa , Encaminhamento e Consulta
7.
Rev. baiana saúde pública ; 45(3): 253-263, 20213112.
Artigo em Português | LILACS | ID: biblio-1393129

RESUMO

A Covid-19 é uma doença causada pelo betacoronavírus SARS-CoV-2. O vírus é transmitido pelo contato interpessoal próximo, por meio de gotículas respiratórias. Dentre as medidas de prevenção contra contágio e disseminação da doença, é recomendado a higienização das mãos com água e sabão e/ou álcool em gel e o afastamento social, uso de máscaras de pano e a aferição da temperatura utilizando termômetro digital infravermelho para o controle de acesso nos ambientes públicos, a fim de impedir possíveis portadores sintomáticos do vírus. Temos por objetivo, refletir sobre a eficácia da aferição da temperatura em ambientes públicos utilizando termômetro digital com sensor de infravermelho. Baseado nos conhecimentos da fisiologia da temperatura corporal e processos febris, apresentados na literatura especializada, e na experiência da identificação de portadores utilizando o procedimento de aferição de temperatura descrito, é evidente a necessidade de uma elaboração de políticas públicas de combate à pandemia mais abrangente, que enfatize a necessidade do conjunto das medidas sanitárias. Aliado a isso, é necessário um programa de testagem contínuo e em massa, permitindo o mapeamento e a busca por auxílio e orientação médica especializada, bem como um programa de educação e conscientização da população para a necessidade de quarentena e isolamento social em casos suspeitos que apresentem sintomas de pirexia.


Covid-19 is a disease caused by the betacoronavirus SARS-CoV-2, which is transmitted through close interpersonal contact through respiratory droplets. Among the preventive measures against contagion and dissemination, the guidelines recommend hand hygiene with water and soap or hand sanitizer, social withdrawal, use of cloth masks and temperature measurement using digital infrared thermometer for access control in public environments to prevent possible symptomatic carriers. This study sought to reflect on the effectiveness of measuring temperature in public environments using a digital infrared thermometer. Based on specialized literature on body temperature physiology and febrile response, as well as on the practice of carrier identification by temperature measurement, the research point to the need of elaborating more comprehensive public policies to combat the pandemic, emphasizing a combination of health measures. Moreover, a continuous and mass testing program is needed, allowing the mapping and search for specialized medical help, as well as an education and awareness program on the need for quarantine and social isolation is symptomatic carriers.


Covid-19 es la enfermedad causada por el betacoronavirus SARS-CoV-2. El virus se transmite por contacto interpersonal cercano, a través de gotitas respiratorias. Entre las medidas preventivas contra el contagio y propagación de la enfermedad, se recomiendan la higiene de manos con agua y jabón y / o gel de alcohol y el retraimiento social, el uso de mascarillas de tela y la medición de la temperatura mediante un termómetro digital infrarrojo para su control. para prevenir posibles portadores sintomáticos del virus. Nuestro objetivo es reflexionar sobre la efectividad de medir la temperatura en entornos públicos utilizando un termómetro digital con sensor de infrarrojos. Con base en el conocimiento de la fisiología de la temperatura corporal y los procesos febriles, presentado en la literatura especializada, y en la experiencia de identificación de portadores mediante el procedimiento de medición de temperatura descrito, se evidencia la necesidad de la elaboración de una política pública más integral para combatir la pandemia., que enfatiza la necesidad de todas las medidas sanitarias. A ello se suma un programa de pruebas continuas y masivas, que permitan el mapeo y búsqueda de asistencia y orientación médica especializada, así como un programa de educación y sensibilización de la población sobre la necesidad de cuarentena y aislamiento social en casos sospechosos, que presentan síntomas del pirexia.


Assuntos
Sinais e Sintomas , Controle de Acesso , Prevenção de Doenças , Pandemias , Febre , Higiene das Mãos , Betacoronavirus , SARS-CoV-2 , COVID-19
8.
Narrat Inq Bioeth ; 11(1): 101-105, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34334484

RESUMO

In early 2020, clinicians and researchers rushed to understand the SARS-CoV-2 virus and how to go about treating and preventing it. Caring for patients while simultaneously learning about a disease not seen before created challenges on several levels. Much of the spotlight was on the researchers doing this critical work; however, these narratives remind us of the enormous effort and commitment shown by IRB members and research administrators responsible for research infrastructure. Despite the sense of urgency and obligation to plan and conduct clinical research during the pandemic, IRBs guaranteed that researchers still adhered to the core ethical principles that protect the rights and welfare of human subjects so that critical research could continue. Many themes emerge in these stories, including the need for flexibility in processes for both staff and research participants and the perception that IRB members serve as "research gatekeepers." With approaches to clinical research evolving, the SARS-CoV-2 pandemic may be the catalyst needed to make sustainable improvements to our research processes, roles, and goals.


Assuntos
Pesquisa Biomédica/ética , COVID-19 , Comitês de Ética em Pesquisa , Pandemias , Ética em Pesquisa , Controle de Acesso , Humanos , Narração , Pesquisadores , Sujeitos da Pesquisa , SARS-CoV-2
9.
Front Public Health ; 9: 665282, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34249837

RESUMO

Introduction: Gatekeeping mechanism of primary care institutions (PCIs) is essential in promoting tiered healthcare delivery system in China. However, patients seeking for higher-level institutions instead of gatekeepers as their first contact has persisted in the past decade. This study aims to explain patients' choice and willingness and to provide potential solutions. Methods: A survey was conducted among residents who had received medical care within the previous 14 days. Patients' choice and willingness of PCIs for first contact together with influencing factors were analyzed using binary logistic regression. Results: Of 728 sampled patients in Hubei, 55.22% chose PCIs for first contact. Patients who are older, less educated, with lower family income, not living near non-PCIs, with better self-perceived health status, only buying medicines, and living in rural instead of urban area had significantly higher probability of choosing PCIs. As of willingness, over 90% of the patients inclined to have the same choice for their first contact under similar health conditions. Service capability was the primary reason limiting patients' choice of PCIs. Conclusions: The gatekeeper system did not achieve its goal which was 70% of PCIs among all kinds of institutions for first contact. Future measures should aim to improve gate-keepers' capability.


Assuntos
Atenção à Saúde , Preferência do Paciente , China , Estudos Transversais , Controle de Acesso , Humanos
10.
J Pastoral Care Counsel ; 75(2): 84-91, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34137332

RESUMO

801 U.S. Catholic, Jewish and Protestant clergy reported on their suicide gatekeeping activities. Using vignettes, they identified suicide risk and selected interventions for three risk levels. Two-thirds of the sample who provide counseling reported at least one contact from a suicidal person per year. Clergy were significantly more concurrent with experts in identifying risk and selecting interventions with high risk but deviated more from the experts with low and medium risk. Most reported needing more training.


Assuntos
Assistência Religiosa , Suicídio , Clero , Controle de Acesso , Humanos , Protestantismo , Suicídio/prevenção & controle
11.
JNCI Cancer Spectr ; 5(3)2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34104866

RESUMO

Background: Although it is well documented that adolescents and young adults (AYAs) with cancer have low participation in cancer clinical trials (CCTs), the underlying reasons are not well understood. We used the National Cancer Institute Community Oncology Research Program (NCORP) network to identify barriers and facilitators to AYA CCT enrollment, and strategies to improve enrollment at community-based and minority and/or underserved sites. Methods: We performed one-on-one semistructured qualitative interviews with stakeholders (NCORP site principle investigators, NCORP administrators, physicians involved in enrollment, lead clinical research associates or clinical research nurses, nurse navigators, regulatory research associates, patient advocates) in the AYA CCT enrollment process. NCORP sites that included high and low AYA-enrolling affiliate sites and were diverse in geography and department representation (eg, pediatrics, medical oncology) were invited to participate. All interviews were recorded and transcribed. Themes related to barriers and facilitators and strategies to improve enrollment were identified. Results: We conducted 43 interviews across 10 NCORP sites. Eleven barriers and 13 facilitators to AYA enrollment were identified. Main barriers included perceived limited trial availability and eligibility, physician gatekeeping, lack of provider and research staff time, and financial constraints. Main facilitators and strategies to improve AYA enrollment included having a patient screening process, physician endorsement of trials, an "AYA champion" on site, and strong communication between medical and pediatric oncology. Conclusions: Stakeholders identified several opportunities to address barriers contributing to low AYA CCT enrollment at community-based and minority and/or underserved sites. Results of this study will inform development and implementation of targeted interventions to increase AYA CCT enrollment.


Assuntos
Ensaios Clínicos como Assunto , Acesso aos Serviços de Saúde , Seleção de Pacientes , Adolescente , Controle de Acesso , Humanos , National Cancer Institute (U.S.) , Defesa do Paciente , Pesquisa Qualitativa , Pesquisadores , Participação dos Interessados , Estados Unidos , Adulto Jovem
12.
Soc Sci Med ; 290: 113891, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34045085

RESUMO

In medical decision-making, doctors have to take into consideration whether patients' expectations can be satisfied while appropriately allocating medical resources. This study explores how recommendations for no further treatment, or gate-closing recommendations, are resisted by patients and how doctors react to resistance in outpatient consultations at a university hospital in Japan. We show how the type of patient resistance shapes doctors' reactions. Problem-focused resistance problematizes the doctor's understanding of the patient's problem or the treatment itself without focusing on the gate-closing aspect of a recommendation, and is met with doctors' persuasion through diagnosis-based accounts. Provider-focused resistance focuses on the gate-closing aspect of a recommendation, and leads doctors to manage their dual roles as patient advocate and resource steward. Two subtypes of provider-focused resistance further shape this work differently. Unwillingness-focused resistance is met with persuasion mainly through institution-based accounts. Unavailability-focused resistance is met with a concession. Doctors systematically respond to patients' resistance in order to reach an agreement during decision-making. They take measures to reconcile their dual roles, and orient themselves toward the implicit rationale of gatekeeping, which has a moral nature.


Assuntos
Controle de Acesso , Médicos , Hospitais , Humanos , Japão , Relações Médico-Paciente , Encaminhamento e Consulta
13.
Scand J Prim Health Care ; 39(2): 139-147, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33792485

RESUMO

BACKGROUND: Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor's consultation, which may lead to busy sessions and in turn impair clinical decisions. OBJECTIVE: This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers. METHODS: We conducted four focus groups with 22 nurses (five men and 17 women aged 24-66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation. RESULTS: The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population's use of out-of-hours services. They also described callers' characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments. CONCLUSIONS: Nurses perceive assessments of callers with respiratory tract infections as challenging. They need skills and time to reach a consensus with the callers and guide them to the right level of health care. This should be considered when planning nurse training and staffing of out-of-hours cooperatives.KEY-POINTSPhone triage nurses assess callers to the out-of-hours service and estimate the level of urgencyThis study explores how phone triage nurses assess callers with respiratory tract infections and their views and experiences on this taskThe nurses describe their professional role as a tightrope walk between gatekeeping and service providingThe nurses seek consensus with callers through strategies and negotiations.


Assuntos
Enfermeiras e Enfermeiros , Infecções Respiratórias , Feminino , Controle de Acesso , Humanos , Masculino , Infecções Respiratórias/diagnóstico , Telefone , Triagem
14.
Nord J Psychiatry ; 75(5): 370-377, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33428517

RESUMO

BACKGROUND: Sexual abuse is associated with severe health consequences, and the European Union has, through the Istanbul Convention, urged its member countries to provide specialist care for victims of sexual abuse. AIM: This aim of this study was to investigate patient- and abuse-related characteristics among patients seeking help at a specialist clinic in Sweden, with focus on disclosure, mental health and appropriate healthcare access. METHODS: This is a descriptive study where journal data from 100 consecutive patients January 2017 to February 2018 were analyzed. All adult individuals (women n = 80, men n = 8) who had taken part in the standardized semi-structured intake interview at the clinic were included (n = 88). RESULTS: At admission, mean age was 40.3 (SD 11.9), mean number of psychiatric diagnoses 6.3 (2.6), and 93% of the patients scored above cut-off (≥34) on IES-R for PTSD. A majority of the patients (87%) had been exposed to childhood sexual abuse (CSA), and mean time to first disclosure was 15.9 (SD 15.3) years. In total, 82% of the patients had, despite disclosure, experienced difficulties accessing appropriate healthcare before coming to the specialist clinic. CONCLUSION: Adult victims of sexual abuse have difficulties accessing appropriate healthcare. This constitutes a gender-based equality problem. A model of gatekeeping mechanisms with two dimensions (external and internal) and three categories (Competence related, Organizational and Emotional) is proposed to understand these difficulties.


Assuntos
Abuso Sexual na Infância , Maus-Tratos Infantis , Vítimas de Crime , Adulto , Criança , Feminino , Controle de Acesso , Acesso aos Serviços de Saúde , Humanos , Masculino , Suécia
15.
BMJ Glob Health ; 5(8)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32792410

RESUMO

INTRODUCTION: This paper evaluates the effectiveness of a gatekeeping pilot in shifting resources and patient visits from hospitals to primary care facilities under the Chinese New Rural Cooperative Medical Scheme. METHODS: We applied a difference-in-differences regression analysis using claims data from a pilot district in northern China. The study covered 200 685 enrollees in 17 townships in 2012 and followed-up the townships over 12 year-quarters until the end of 2014. RESULTS: The gatekeeping pilot led to significantly more patients visiting primary care facilities (55.3%, p=0.001), but there was little evidence of increased ambulatory spending on primary care (1.6%, p=0.884). The pilot reduced hospital visits by 23.9% (p=0.048) and ambulatory spending at the hospitals by 22.4% (p=0.011). CONCLUSIONS: This first impact evaluation of gatekeeping outside high-income countries found that gatekeeping policy did not seem to have expanded the care provided by primary care facilities, despite an increased volume of claimed visits. Although claimed patient visits and expenditure at hospitals reduced, we suspect this may have been because patients found it either cumbersome or difficult to obtain reimbursement for their care.


Assuntos
Controle de Acesso , Atenção Primária à Saúde , China , Gastos em Saúde , Humanos , População Rural
16.
Trop Med Int Health ; 25(10): 1205-1213, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32687625

RESUMO

OBJECTIVES: Suicide by pesticide self-poisoning is a major public health challenge in low- and middle-income countries. While effectiveness studies are required to test alternative prevention approaches, economic evidence is lacking to inform decision-making in research priority setting. Therefore, this study aimed to estimate the costs of a shop-based gatekeeper training programme for pesticide vendors seeking to prevent pesticide self-poisoning in rural Sri Lanka and assess its potential for cost-effectiveness. METHODS: Ex-ante cost and cost-effectiveness threshold (CET) analyses were performed from a governmental perspective based on a three-year analytic horizon, using 'no programme' as a comparator. A programme model targeting all 535 pesticide shops in the North Central Province and border areas was applied. Total programme costs (TPC) were estimated in 2019 USD using an ingredients approach and 3% annual discounting. The Sri Lankan gross domestic product per capita and life years saved were used as CET and effectiveness measure, respectively. Sensitivity analyses were performed. RESULTS: TPC were estimated at 31 603.03 USD. TPC were sensitive to cost changes of training material and equipment and the programme lifetime. The programme needs to prevent an estimated 0.23 fatal pesticide self-poisoning cases over three years to be considered cost-effective. In the sensitivity analyses, the highest number of fatal cases needed to be prevented to obtain cost-effectiveness was 4.55 over three years. CONCLUSIONS: From an economic perspective, the programme has a very high potential to be cost-effective. Research assessing its effectiveness should therefore be completed, and research analysing its transferability to other settings prioritised.


OBJECTIFS: Le suicide par auto-intoxication par les pesticides est un défi majeur de santé publique dans les pays à revenu faible ou intermédiaire. Bien que des études d'efficacité soient nécessaires pour tester d'autres approches de prévention, les données économiques manquent pour informer la prise de décision dans les priorités de recherche. Par conséquent, cette étude visait à estimer les coûts d'un programme de formation des vendeurs dans les magasins de pesticides visant à prévenir l'auto-intoxication par les pesticides dans les régions rurales du Sri Lanka et à évaluer son potentiel de rentabilité. MÉTHODES: Les analyses ex-ante des coûts et des seuils de rentabilité (SR) ont été réalisées dans une perspective gouvernementale sur la base d'un horizon analytique de trois ans, en utilisant «l'absence de programme¼ comme comparateur. Un modèle de programme ciblant les 535 magasins de pesticides de la province du Centre-Nord et des zones frontalières a été appliqué. Les coûts totaux du programme (CTP) ont été estimés en USD 2019 en utilisant une approche d'ingrédients et une remise annuelle de 3%. Le produit intérieur brut sri-lankais par habitant et les années de vie sauvées ont été utilisés comme SR et mesure d'efficacité, respectivement. Des analyses de sensibilité ont été effectuées. RÉSULTATS: le CTP a été estimé à 31.603,03 USD. Le CTP était sensible aux changements de coût du matériel et de l'équipement de formation et de la durée de vie du programme. Le programme devrait prévenir environ 0,23 cas d'auto-intoxication mortelle par des pesticide sur trois ans pour être considéré comme rentable. Dans les analyses de sensibilité, le plus grand nombre de cas mortels à prévenir pour obtenir une rentabilité était de 4,55 sur trois ans. CONCLUSIONS: D'un point de vue économique, le programme a un potentiel très élevé pour être rentable. La recherche évaluant son efficacité doit donc être complétée et la recherche analysant sa transférabilité à d'autres contextes doit être priorisée.


Assuntos
Comércio , Educação/economia , Controle de Acesso/economia , Praguicidas/envenenamento , Tentativa de Suicídio/prevenção & controle , Análise Custo-Benefício , Humanos , Praguicidas/economia , População Rural , Sri Lanka
17.
BMC Fam Pract ; 21(1): 110, 2020 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-32552721

RESUMO

BACKGROUND: In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients' willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. METHODS: Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. RESULTS: Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: + 1.14 points, p < 0.001), morbidity (+ 0.10 per disease, p = 0.043), education (high vs. low: - 1.74, p < 0.001), logarithmised household net adjusted disposable income (- 0.93 per step on the logarithmic scale, p = 0.004), regional category (urban areas: - 0.85, p = 0.022; environs: - 0.80, p = 0.045) and healthcare utilisation (each GP contact: + 0.30, p < 0.001; each contact to a medical specialist: - 0.75, p = 0.018). Professional situation and age were not significantly associated with the GP commitment. CONCLUSION: On average, the patients' commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov (NCT02558322).


Assuntos
Atenção à Saúde , Controle de Acesso , Medicina Geral , Clínicos Gerais/provisão & distribuição , Sobremedicalização/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Estudos Transversais , Atenção à Saúde/métodos , Atenção à Saúde/organização & administração , Feminino , Controle de Acesso/normas , Controle de Acesso/estatística & dados numéricos , Medicina Geral/organização & administração , Medicina Geral/estatística & dados numéricos , Alemanha/epidemiologia , Humanos , Masculino , Preferência do Paciente , Encaminhamento e Consulta/estatística & dados numéricos , Saúde da População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Saúde da População Urbana/estatística & dados numéricos
18.
Langmuir ; 36(24): 6757-6764, 2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32450698

RESUMO

Tight junction pores are physiological gatekeepers of paracellular transport in epithelial tissues. Conventionally, tight junction permeability is determined via in vitro electrophysiology measurements; however, the macroscopic readout does not provide molecular-level understanding into the mechanism of ion permeation. Insight into the factors governing selectivity across the paracellular space is just emerging. In this study, we investigated tight junction pores comprising of claudin-2 and claudin-5 proteins that are structurally similar to subnanometer radii but have measurably different in vitro ion permeabilities. To evaluate the mechanistic differences in ion transport across the pores, we computed the free-energy profiles and relative rate constants for the transport of monovalent (Na+, K+, Cl-) and divalent (Mg2+ and Ca2+) ions through the pores using replica exchange metadynamics. In claudin-2, we demonstrate how a single residue dictates selective permeability of Na+ and K+ ions. In claudin-5, we found no clear preference for anion or cation selectivity; thus, pores formed by claudin-5 are indeed barriers to ion permeation. Mutations to claudin-5 that widen the pore's steric radius did not significantly impact pore selectivity, indicating that electrostatics dominate pore selectivity. The key takeaways from this work are as follows: (a) two pores that are similar in diameter and length can have dissimilar ion conductance, (b) existence of a physical pore does not guarantee ion permeability, and (c) the electrostatic environment created by the pore-lining residues dictates the ion conductivity. These mechanistic understandings of the tight junction pores are critical for the interpretation of tight junction physiology.


Assuntos
Controle de Acesso , Junções Íntimas , Ânions , Cátions , Permeabilidade
19.
Health Econ ; 29(7): 778-789, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32285524

RESUMO

In social insurance systems that grant workers paid sick leave, physicians act as gatekeepers, supposedly granting sickness certificates to the sick and not to shirkers. Previous research has emphasized the physician's superior ability to judge patients' need of treatment and potential collusion with the patient vis-á-vis an insurer. What is less well understood is the role of patients' private information. We explore the case where patients have private information about the presence of nonverifiable symptoms. Anyone can then claim to experience such symptoms, reducing physicians' ability to distinguish between sick patients and shirkers. Doubting a patients' reported symptoms may prevent good medical treatment of the truly sick. We show that for all parameter values, the Bayesian Nash equilibrium is that some physicians trust all claims of nonverifiable symptoms, sicklisting shirkers as well as sick; for many values, every physician is trusting. In particular, if physician strategies are observable by patients, extremely strong gatekeeping preferences are required to make physicians mistrust. To limit unwarranted sicklisting, policies reducing the benefits of shirking for healthy workers may be better suited than attempts to convince physicians to be strict.


Assuntos
Ftirápteros , Médicos , Animais , Teorema de Bayes , Controle de Acesso , Humanos , Padrões de Prática Médica , Licença Médica
20.
Cancer Med ; 9(12): 4107-4113, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32314549

RESUMO

BACKGROUND: Perspectives of clinical trial (CT) personnel on accrual to oncology CTs are relatively absent from the literature. This study explores CT personnel's experience recruiting patients to oncology CTs. METHODS: A qualitative study design was utilized. In-depth, individual interviews with 12 oncology CT personnel were conducted, including six CT nurses and six physician-investigators. Interviews were digitally recorded and transcribed verbatim. Data were subjected to thematic and ethical analysis to identify key concepts and themes. RESULTS: CT personnel reported considering two ethical commitments in CT recruitment: maintaining trial integrity and ensuring patient autonomy through obtaining informed consent. The process of gatekeeping emerged as a way to navigate these ethical commitments during CT accrual. Gatekeeping was influenced by: (a) perceptions of patients' personal suitability for a trial, and (b) healthcare resources and infrastructure. CT personnel's discernment of personal suitability was influenced by patients' cognitive and mental health status, language and cultural background, geographic location, family support, and disease status. Three structural factors impacted gatekeeping: complexity of CTs, consent process, and time limitations in the healthcare system. CT personnel experienced most factors as constraints to accrual and gaining patients' informed consent. CONCLUSION: CT personnel discussed navigating ethical challenges in CT recruitment by offering enrollment to specific patient populations, exacerbating other ethical tensions. Systems-level strategies are needed to address barriers to ethical CT recruitment. Future research should investigate the role of policies and/or tools (eg, decision aids) to support patients and CT personnel's discussions about CT participation, promote more ethical recruitment, and potentially increase accrual.


Assuntos
Pesquisa Biomédica/ética , Ensaios Clínicos como Assunto/métodos , Tomada de Decisões/ética , Consentimento Livre e Esclarecido/ética , Neoplasias/terapia , Seleção de Pacientes/ética , Pesquisadores/psicologia , Ensaios Clínicos como Assunto/psicologia , Feminino , Controle de Acesso , Humanos , Masculino , Participação do Paciente , Pesquisa Qualitativa , Pesquisadores/ética , Inquéritos e Questionários
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