Personal paper: medicine in the 1990s needs a team approach

Health care increasingly emphasises the team approach in which doctors, nurses, and other health workers adapt and develop new skills. Before changes of this kind are widely accepted, however, there must be clarity about the training, status, authority, working relationships, career structure, and remuneration of those who undertake responsibilities well beyond their traditional roles.     

Occupational medicine and quality

The discipline of occupational medicine has always maintained a closed relationship with the quality system, starting from the well known quality assurance practices, up to the quality of health services, and the concept of prevention and health promotion as essential components of quality programs. The quality of health care has emerged as an area of high interest and concern, driven by the consideration of public policy and the desire of health care government to maximize the value of their investments. However, when we move to apply quality principles to health service some difficulties emerge. For example the introduction of DRFs system makes uneconomical the diagnosis in occupational medicine, since the costs are determined by the type and the number of hazards to be identified and assessed and not only by the risk factors of by the worker's pathology. Moreover, resources are necessary for the correct evaluation of non occupational pathologies often present, both for deontological and legal reasons. The attention to the role of occupational medicine in quality programs has been increased by the recognition of the adverse impact of preventable or controllable risk factors in health benefit and disability costs and employee productivity. By this way prevention and health promotion will become an essential part of quality procedures able to guarantee and maintain quality objectives.     

Selective shunts in the 1990s

Venous thrombosis is a well-known complication of permanent cardiac pacemaker implantation, particularly, chronic occlusion of the subclavian vein is reported to occur in 20-33% of the cases where the percutaneous approach is performed. We examined 135 asymptomatic patients with digital venography to asses the frequency of venous thromboses causing stenosis and occlusion of the subclavian or anonymous arteries in pacemaker carriers. We considered both one- (44) and two-chamber (91) pacemakers and investigated a possible statistically significant difference between them: we found 21 venous thromboses (15%), seven of them in one-chamber pacemakers (15.9%) and 14 two-chambers pacemakers (15.3%). None of our 94 male and 41 female patients was on anticoagulants or had any evidence of coagulation disorders. Venography was performed 39.3 months (mean) after pacemaker implantation (range: 3-120 months). We conclude that digital venography is a simple and relatively noninvasive method permitting better depiction of subclavian, anonymous and caval veins than Doppler US and also showing some vascular abnormalities which may complicate pacemaker implantation.     

Hypospadias repair in the 1990s

Hypospadias is a congenital anomaly in which the urethral meatus is abnormally located anywhere from the glans to the perineum. Refinements in pediatric anesthesia, surgical technique and instrumentation, and a greater understanding of the psychologic and emotional issues related to hypospadias repair have led to this procedure being performed at an earlier age. The goal of reconstruction is to bring the urethral meatus to the tip of the penis, to correct associated penile curvature if present, to create a conical-shaped glans, and to achieve cosmetically acceptable penile shaft skin coverage. The surgical technique employed varies with the penile anatomy and surgeon's preference. Complications may occur both immediately and long after the surgical procedure, and thus follow-up is necessary.     

The professions in the 1990s

As they did when they were formed 150 years ago, the professions must again convince the public and a cost-conscious and competition-orientated Government that they should be entrusted with the provision of services their training has made them fit to offer. This article explains why.     

Addiction and AIDS in the 1990s.

Predicts that psychologists treating addiction will be vigorously involved with combating acquired immune deficiency syndrome (AIDS) in the 1990s. Psychologists will need to be committed to preventing the spread of human immunodeficiency virus (HIV), understanding the AIDS–drug use connection, and devising means to minimize the effects of infection on drug users, staff members who treat them, and the general population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Geriatric care in the late 1990s

Geriatric health care remains a virtually untapped area in spite of changing public views and scientific knowledge on aging. The number of older dogs and cats will continue to grow into the next century. Owners of older dogs and cats are willing to invest in quality health care services. A geriatric health care program can expand veterinary services in a practice and is a natural extension of pediatric and adult maintenance programs.     

Cancer: incidence and deaths in Canada, 1990

The results of superselective intra-arterial chemotherapy with Mitomycin C (SIAC) in cases of hepatic neoplasms continue to be poor. Survival time was related to the percentage of hepatic replacement (PHR) but only 19% of the patients with Stage I tumours (PHR < 25%) survived for over 5 years and all the others died within 4 years. The patients with hepatic metastases from colorectal cancer achieved a significantly better cumulative 5-year survival figure than those with hepatocellular cancer (P < 0.05). The median survival times for patients with hepatic metastases from colorectal cancer, hepatocellular cancer and gallbladder cancer were 15 months, 6 months and 13 months, respectively. The overall response rate was only 27% (26/97), that for primary liver cancer 20% (7/35), that for hepatic metastases from colorectal cancer 22% (8/37) and that for gallbladder cancer 44% (11/25) and the patients who responded to SIAC (n = 27) had a significantly better cumulative 5-year survival rate (P < 0.005). Cessation of SIAC was necessary in 74% (72/97) of the cases, because of tumour progression in 53% (51/97), major complications in 19% (18/97) and patient refusal in 3% (3/97). The results of this trial may be regarded as disappointing, and we are going to use SIAC for Stage I tumours only. Resection of the tumour continues to provide the only chance of a permanent cure with these patients.     

Introduction to the special issue on behavioral medicine: An update for the 1990s.

The current issue of the Journal of Consulting and Clinical Psychology represents a 10-year update on a previous 1982 special issue devoted to behavioral medicine. Research, especially treatment research since 1981, is summarized across a number of topics. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Prevention and control of tuberculosis in the 1990s

Beginning in 1984, the long-term decline in tuberculosis (TB) cases stopped, and since 1985 the number of cases has actually increased by 18%, from 22,201 new cases in 1985 to 26,283 in 1991. The change in the morbidity trend appears to be primarily due to three factors: HIV coinfection, TB occurring in persons from countries where this disease is prevalent, and deterioration of the health care infrastructure with resultant outbreaks of TB. This article presents six interventions that address major areas where action is needed. These efforts will require coordinated action by health care providers, public health departments, and other public and private organizations. Protection of all workers and patients in health care settings is one important goal of these efforts.     

Understanding family relationships in the late 1990s

No one marries only an individual. Each marries the partner plus his or her kin, parents, grandparents, and siblings. Marriage and inlaws are discussed.     

Catching patients: tuberculosis and detention in the 1990s

The resurgence of tuberculosis (TB) in the early 1990s, including multidrug-resistant strains, led health officials to recommend the use of involuntary detention for persistently nonadherent patients. Using a series of recently published articles on the subject, this paper offers some opinions on how detention programs have balanced protection of the public's health with patients' civil liberties. Detained persons are more likely than other TB patients to come from socially disadvantaged groups. Health departments have generally used coercion appropriately, detaining patients as a last resort and providing them with due process. Yet health officials still retain great authority to bypass "least restrictive alternatives" in certain cases and to detain noninfectious patients for months or years. Misbehavior within institutions may inappropriately be used as a marker of future nonadherence with medications. As rates of TB and attention to the disease again decline, forcible confinement of sick patients should be reserved for those persons who truly threaten the public's health.     

Dynamic cost shifting in hospitals: evidence from the 1980s and 1990s

The purpose of this paper is to determine whether dynamic cost shifting occurred among acute care hospitals during the period from the early 1980s to the early 1990s and, if so, whether market factors affected the ability to shift costs. Evidence from this study of California acute care hospitals during three time intervals shows that the hospital did practice dynamic cost shifting, but that their ability to shift costs decreased over time. Surprisingly, hospital competition and HMO penetration did not influence cost shifting. However, increasing HMO penetration (measured as the HMO percentage of hospital discharges) did decrease both net prices and costs for the early part of the study, but later was associated with increases in both.