"Where have all the children gone"? Inpatient pediatric care in Connecticut

Admission of children to hospitals in Connecticut dropped precipitously from 1981 to 1991. Regionalization of pediatric inpatient care is happening without plan. Connecticut data show a change in case-mix of pediatric cases, especially in surgical services and child mental illness categories. Planning for pediatric inpatient services should include considerations of case-mix, cost, and especially, quality of care in general hospital pediatric units with very low volume.     

Max Sandreczky: a pediatric surgeon in 19th-century Jerusalem

Until the mid-19th century, there had not been a single resident physician in the Holy Land. However, by the first World War in 1914, 19 hospitals had been established in Jerusalem. The reasons for this unusual phenomenon were religious, political, and sectarian. This does not apply to The Marienstift Kinderhospital, which was unique in 19th century Jerusalem. The hospital was founded and operated by Dr Max Sandreczky, a German pediatric surgeon. The standards of medical and surgical practice in the hospital not only compared favorably with those in western Europe, but, in certain aspects, they were more advanced. The Marienstift Kinderhospital was an "implant" of a western institution in a society that was medieval in character. The response of this society was studied as well as the natural history of this unique institution and its medical director, the pediatric surgeon, Dr Max Sandreczky.     

Helicopter use in the Swiss air rescue service for children. Inland transport in 1992

In 1992, the Swiss helicopter rescue service (REGA) transported 515 injured and 141 sick children (total n = 656). More than 60% of the children were boys; the age group from 10 to 16 years dominated. Primary care was provided in 415 of the flights, whereas the remaining cases were interhospital transfers to institutions with pediatric intensive care units. The main reason for primary interventions was sports accidents, followed by medical disease and traffic accidents. The majority of the sick children (70%) were severely ill with life-threatening diseases according to National Advisory Committee for Aeronautics (NACA) indices IV to VII. On the other hand, only 47% of the injured children had NACA indices of IV to VII. Most of these children had minor injuries suffered during sports activities; they were rescued mainly because of the site of the accident and not the severity of the injury. The remaining trauma victims had had traffic or home accidents and were usually severely injured. Head injuries were the most common reason for intervention due to accidents, and central nervous disorders and respiratory problems were the main reason for interventions in children suffering from serious illnesses. For primary REGA rescue interventions, the mean time from accident to arrival at the hospital was 64 minutes: 18 minutes from injury to alarm, 17 minutes from alarm to arrival at the scene, and 29 minutes for scene time and flight to the hospital. Costs for helicopter rescue are twice as high as for ground-based rescue (ambulance). However, considering the relatively high percentage of severely injured or life-threatened sick children involved, air rescue and its higher costs appear to be justified.     

St Jude Children's Research Hospital's International Outreach Program

Over 80% of children with cancer live in developing countries, where access to medical services is limited to varying degrees. In many of these countries, economic conditions and general health care have improved sufficiently to permit the development of more sophisticated medical services. The introduction of pediatric oncology programs becomes appropriate as deaths from malnutrition and infections decrease and cancer emerges as an important cause of childhood mortality. In the absence of such services, the worldwide war against pediatric cancer will ultimately be lost because of the rapidly growing pediatric populations in developing countries that now lack the facilities and expertise to treat childhood malignancies. We believe that the development of pediatric cancer centers in many of these countries is both appropriate and feasible. Partnerships in which established pediatric oncology centers work with the governments and private sectors of developing nations to implement key facilities are an efficient and cost-effective way to introduce such services. The challenges of these outreach efforts are significant -- as are the expected benefits.     

The role of the primary care physician in the care of children with serious heart disease

OBJECTIVE: To determine the roles of primary care physicians and specialists in the medical care of children with serious heart disease. SETTING: Pediatric Cardiology Division; Tertiary Care Children's Hospital. SUBJECTS: Convenience sample of parents, primary care physicians, and pediatric cardiologists of 92 children with serious heart disease. DESIGN: Questionnaire study; questionnaires based on 16 medical care needs, encompassing basic primary care services, care specific to the child's heart disease and general issues related to chronic illness. RESULTS: All children had a primary care physician (PCP), and both they and the parents (P) reported high utilization of PCP for basic primary care services. However, there was little involvement of PCP in providing care for virtually any aspect of the child's heart disease. Parents expressed a low level of confidence in the ability of PCP in general or their child's own PCP to meet many of their child's medical care needs. Both PCP and pediatric cardiologists (PC) were significantly more likely than parents to see a role for PCP in providing for care specific to the heart disease as well as more general issues related to chronic illness. PC and PCP generally agreed about the role PCP should play, although PC saw a bigger role for PCP in providing advice about the child's activity than PCP themselves did. PC were less likely to see the PCP as able to follow the child for long term complications than PCP did. PC were more likely than PCP to believe that PCP were too busy or were inadequately reimbursed to care for children with serious heart disease. Only about one-third of parents reported discussing psychosocial, family, economic, or genetic issues with any provider, and PCP were rarely involved in these aspects of chronic illness. CONCLUSIONS: Primary care physicians do not take an active role in managing either the condition-specific or the more general aspects of this serious chronic childhood illness. With appropriate information and support from their specialist colleagues primary care physicians could provide much of the care for this group of children. Generalists and specialists are both responsible for educating and influencing parents about the role primary care physicians can play in caring for children with serious chronic illness.     

History of the public health policy in Chad 1900-1995

Public health policy in Chad began after colonization in 1899 and remained under the control of French Army Medical Corps for a long time. Military doctors shared their time between treating service personnel and indigenous people entitled Medical Assistance and making rounds in their sector. Since independence public health in the country has been based on a two-pronged association including fixed facilities (hospitals and dispensaries) and mobile services such as the Endemic Disease Unit whose most notable success was control of sleeping sickness in the southern part of the country. Over the years Chad has built up a national medical staff comprising 150 physicians. A medical school was opened in N'Djamena in 1990 and paramedical personnel are now trained at the National School for Public Health. War and lack of funds interrupted mobile services and there is presently a recrudescence of sleeping sickness. Since 1990 the World Health Organization has imposed its views and primary care is now available for all. However, it is now too early to judge the efficacity of this program in Chad.     

Psychology and primary health care for children.

There is an emerging consensus among those responsible for primary health care to children that such care should not only include medical concerns but also should assist parents with common problems of development and behavior. Psychologists are increasingly included among the personnel of medical groups that provide primary care to children. A model for this relatively new type of practice is described. Such pediatric primary-care settings also offer new research opportunities for psychologists. An important public policy issue concerns how comprehensive primary health care, including psychological services, can be made accessible to all children, and how research to evaluate such services and improve their efficacy can be encouraged. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Tomlinson report and postgraduate medical education

The postgraduate hospitals of London grew up in the nineteenth century and offered a unique national specialist service. Since then specialist services have developed in undergraduate hospitals throughout Britain as well as in London, but the postgraduate hospitals have nevertheless preserved their high levels of staffing. Although numbers of medical posts in the provinces have grown, this has not been by redistribution of London posts but merely differential growth. The fact identified by Tomlinson--that Londoners are not receiving the most appropriate clinical care--is in fact the strongest argument for changing postgraduate medical education. Such education needs to be rooted first in clinical care, though Tomlinson underestimates the importance to education of such care being sited in a shared environment with strong scientific activity.     

National Hospital Ambulatory Medical Care Survey: 1992 Emergency Department Summary

OBJECTIVE: This report presents data on the provision and utilization of ambulatory medical care services in hospital emergency departments during 1992. Ambulatory medical care services are described in terms of patient, visit, and facility characteristics. Among these are the patient's reason for the visit, diagnostic and screening services ordered or provided, diagnosis, and medications provided or prescribed. Cause of injury data are presented for injury-related visits. METHODS: Data presented in this report are from the 1992 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national survey of non-Federal, general and short-stay hospitals, conducted by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention. This report reflects the survey's first year of data collection. A four-stage probability sample design was used, resulting in a sample of 524 non-Federal, general and short-stay hospitals. Ninety-two percent of eligible facilities participated in the survey. Hospital staff were asked to complete Patient Record forms for a systematic random sample of patient visits occurring during a randomly assigned 4-week reporting period, and 36,271 forms were completed by participating emergency departments. Diagnosis and cause of injury were coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Reason for visit and medications were coded according to systems developed by the National Center for Health Statistics. RESULTS: An estimated 89.8 million visits were made to the emergency departments of non-Federal, general and short-stay hospitals in the United States during 1992-357.1 visits per 1,000 persons. Persons 75 years of age and over had a higher visit rate than persons in five other age categories. White persons accounted for 78.5 percent of all visits. However, the visit rate for black persons was significantly higher than for white persons overall and for every age category except 65-74 years and 75 years and over. More than half of all visits were illness related and more than one-third were injury related. Stomach and abdominal pain and chest pain were the most frequently mentioned reasons for visiting the emergency department, accounting for about five million visits each, or 10.7 percent of the total. Accidental falls accounted for the largest share of injury-related visits (22.7 percent).     

Children with encopresis: a study of treatment outcome

A pediatric treatment program for encopresis was established in a large medical center. This consisted of counseling and education, initial bowel catharsis, a supportive maintenance program to potentiate optimum evacuation, retraining, and careful monitoring and follow-up. A group of 127 children received care for this problem. At the end of one year, outcome data were obtained on 110 patients. Of these, 51% had not had "accidents" for more than six months. Another 27% showed marked improvement and were having only rare episodes of incontinence. 14% of these children showed some improvement, but continued to have incontinence, while 8% showed no improvement whatsoever during the treatment year. These four outcome groups were compared with respect to a large number of demographic, developmental, psychosocial, and clinical variables.     

Delivering health and mental health care services to children in family foster care after welfare and health care reform

As the 20th century draws to a close, fundamental changes in the organization, financing, and delivery of health care and welfare services, principally directed at poor families, are likely to result in an increased number of children entering out-of-home care. These children typically have significant physical, mental health, and developmental problems. Whether the quality of health care services they receive will improve as a result of health care reform efforts and new approaches to service delivery remains to be seen. This article addresses some of the major changes wrought by welfare and health care reform and describes the essential features of a health care system that can meet the special needs of children in care.     

League tables and acute myocardial infarction

BACKGROUND: Comparison of the outcomes of care provided by hospitals is a growing trend. Outcomes need to be distinguished into those attributable to the practice of hospitals and those that arise from differences in the characteristics of patients and the underlying morbidity of the populations for whom hospitals provide care. We explored these issues for deaths in hospital or within 30 days of discharge after acute myocardial infarction in Scotland, UK. METHODS: We used records from December, 1992, to November, 1993, for 14,359 episodes of acute myocardial infarction, the death records of those who died, and 9391 death records for individuals who died after acute myocardial infarction but who had not been in hospital in the 30 days before death. Hospital discharge records were taken from the Scottish Morbidity Records. The outcomes we investigated were all-cause mortality within 30 days of discharge from hospital, and death from acute myocardial infarction at any time during the study period. We estimated separately effects attributable to patients' characteristics, hospitals, and areas of residence with multilevel modelling. FINDINGS: We found significant differences between hospitals by age, sex, and medical history. The odds ratios for death ranged from 0.62 (95% CI 0.50-0.80) to 1.28 (1.07-1.59), relative to the average performance for Scotland as a whole. Analysis including area of residence, deaths occurring out of hospital, and more detailed information about patients showed no significant differences between hospitals for patients aged 70 years. By postcode area, there was a strong association between out-of-hospital deaths and deaths in hospital or shortly after discharge. INTERPRETATION: Hospital outcomes may vary from one subgroup of patients to another and should be assessed independently of patients' areas of residence. Measures of performance that do not provide valid comparisons could diminish public confidence in hospital services.     

Issues in mental health services for children and adolescents

Existing system of psychiatric care for children and adolescents is in need of basic reorganization. The authors propose: 1) reestablishment of the speciality of children's and adolescent psychiatrist, a specialist in children's and adolescent narcology, a psychiatrist of early child's age and a pediatric medical psychologist; 2) carrying out the reform of child mental care equal in rights with general psychiatry; 3) preservation and widening of both specialized inpatient and outpatient clinics in general system of child's mental care; 4) legislative and public rehabilitation of children's psychiatry, which suffered considerably from antipsychiatric campaign; 5) professionally organized systematic elevation of psychohygienic, psychiatric and psychotherapeutic knowledges of allied medical and other specialists as well as of parents and of all population too; 6) integration and interaction of govermental services concerning mental health of children and adolescent; 7) organization of regional psychoprophylaxic interdisciplinary centers for children and adolescent.     

The health and welfare system for elderly in France

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.     

The early case for caring for the insane in general hospitals

The early argument for caring for the insane in general hospitals arose in the late 1800s in the context of criticisms of the asylum made by neurologists and some psychiatrists. The movement in support of general hospital psychiatry gained ground within psychiatry as the modernization of the general hospital made it a more attractive work site for physicians. By the second decade of this century, a newly independent discipline of hospital administration was providing an audience for psychiatrists who wanted to make the medical and financial case for the value of psychiatric care in the general hospital. Although in the 1930s only a fraction of general hospitals included a "department for mental patients," general hospital psychiatric treatment had ceased to be only a rhetorical or experimental concept and was fast becoming a practical program of treatment.     

Perioperative blood transfusions and decreased long-term survival in esophageal cancer

BACKGROUND: The aim of this study was to assess accessibility to health care services and the needs of the population and demands on the health service in the areas most affected by the current crisis in the former Yugoslavia. The delivery of health care services and problems in its realization and the status of the population's health in the crisis period (from the second half of 1993 to the end of the first half of 1994) were also investigated together with the results of Government measures concerning health care priorities during the period of UN Sanctions in Yugoslavia. METHOD: By the end of the 1980s, as an alternative to traditional data collection, a new method called 'Rapid Health Assessment' appeared. The EPI design (Experienced Programme on Immunization), the most frequently applied method, was used in this study. It is a cluster sample selection, where a household is the basic unit. RESULTS: This study showed that the first effects of the crisis appeared in the field of health care delivery and then in the population's health status. The difficulties were not the same for all categories of the population, and children and urgent cases had less problems than others. The expected difficulties in vaccination coverage were not shown in this survey. The morbidity structure for children and adults changed in comparison with routine statistical data but the size of the chosen sample, as well as the short period of the crisis investigated, mean that definite conclusions cannot be drawn on this issue. This study provides recent data on health care delivery, morbidity structure, and vaccination coverage, as well as giving a more complex and precise estimate of the real situation.     

Biochemistry and biomechanics of healing tendon: Part I. Effects of rigid plaster casts and functional casts

OBJECTIVE: The state psychiatric hospital is experiencing an increase in medically sick and aging patients who die of natural causes while hospitalized. This study explored the "medicalization" of the state hospital by examining the prevalence of medical illness and its relationship with psychiatric illness and age among state hospital psychiatric inpatients who died of natural causes--deaths that were not accidents, homicides, or suicides. METHODS: A total of 179 inpatients who died of natural causes at Western State Hospital in Washington State between 1989 and 1994 were studied retrospectively through case file review. Their demographic and institutional characteristics and psychiatric diagnoses were compared with those of others treated at the hospital (N=9,258). The medical diagnoses of patients who died were analyzed by age and psychiatric condition. RESULTS: The patients who died were much older than the other patients treated during the study period. Two-thirds of those who died had organic mental disorders, mostly dementia, whereas only a fifth of the other patients had these disorders. The patients who died had a mean of eight physical illnesses, with a range from none to 21. Circulatory and respiratory conditions were most prevalent, affecting half to two-thirds of patients; these conditions had high rates of comorbidity with organic mental disorders. CONCLUSIONS: The characteristics of the state hospital population and the services provided are shifting in response to mental health reform and new policies on patient self-determination. Increased emphasis on medical care added to traditional psychiatric services will require increased financial and personnel resources.     

Reception of Johann Georg Zimmermann's manuscripts in Montpellier]

At the end of the 18th century the French physicians discussed Johann Georg Zimmermann's medical concepts (i.e. medical experience, the influence of the soul on health and disease). In contrast to the German scientists, the French, especially those from the School of Montpellier, accepted Zimmermann's medical views as a confirmation of vitalism and neohippocratic medicine. In Germany, Zimmermann's medical works fell into oblivion after his death until the middle of 20th century. This may be a consequence of his intimate contacts to the European high nobility and of his polemic attacks against friends and enemies as well as his contempt for all forms of democracy and the French Revolution.