A manual on pediatric telephone triage

In 1985 in Zaire, a 12-week training course began in Kasongo district to prepare physicians to use sound management of primary and secondary health services, supervision of health centers, and commitment to team work to operate districts in an integrated way. Only 1 new physician trainee was accepted every 4 weeks. During the first week, trainees observed work at an outpatient clinic for 2-3 hours/day to learn about the links between the primary and secondary levels of health care. During the second week, they observed staff at an urban health center in Kasongo city so they could become familiar with strategies for diagnosis and treatment in curative consultations and with instructions for follow-up. During the third week, the trainees returned to the outpatient clinic to practice interviewing patients. During the fourth week, they observed work in a rural health center and in remote villages. During the second 4-week period, trainees worked in a hospital department of their choice to learn how to use files and to evaluate quality of care. They visited health centers 1-2 times/week to examine supervisory techniques of different resident physicians. Trainees were part of the health team during the third 4-week period. They were responsible for a hospital department and supervised health centers under a resident physician. The trainees also attended management committee meetings addressing quality of care, staff management, and feedback from health center supervisions. The cost for this health district management training was US $100/trainee. Between mid-1985 and mid-1988, 18 physicians underwent this training. 12 of these physicians are now working in health districts in Zaire. A follow-up survey in 1995 showed that most trainees were applying the requisite skills and knowledge acquired during the training. Further supervision or self-training, involving team analysis of problems and possible solutions, are needed. Factors contributing to the course's success include: an integrated health system under the direction of a health team, a large enough team to do student training but small enough to maintain communication, and active participation of trainees.     

Comparison of isradipine and enalapril effects on regional carotid circulation in patients with hypertension with unilateral internal carotid artery stenosis

This randomized, double-blind, placebo-controlled study was aimed at detecting cerebrovascular effects of isradipine and enalapril in patients with moderate hypertension depending on the presence and grade on unilateral stenosis of internal carotid artery (ICA). We evaluated carotid vascular resistance by using Doppler analysis and regional cerebral blood flow (rCBF) by using 133Xe-clearance technique before and after a single 5-mg oral dose of isradipine, enalapril, or placebo. Their effects were randomly and consecutively tested in 73 patients with essential hypertension subdivided into three groups: without carotid occlusive lesions, with moderate (50-75%), and with severe (76-99%) unilateral asymptomatic ICA stenosis. There were no differences in age, gender, and antihypertensive effects of the drugs between these three subgroups. Three major variants of cerebrovascular drug effects were observed: absence of changes (variant I), decrease in carotid vascular resistance with increase in rCBF and elimination of side-to-side asymmetry (variant II), and increase in carotid vascular resistance with further reduction of rCBF ipsilaterally ICA stenosis, and increased side-to-side asymmetry (variant III). Frequency of variant III was significantly higher in patients with severe ICA stenosis. Enalapril produced variant I of cerebrovascular effects in most patients examined; variant III was observed only in 13% of patients with severe ICA stenosis. Isradipine produced variant I of cerebrovascular effects much less frequently than did enalapril. For this drug, variant II was most typical in patients without ICA stenosis and with moderate ICA stenosis. In 43.5% of patients with severe ICA stenosis, however, isradipine produced reduction of cerebral perfusion. Presumably the presence of ICA stenosis, especially >75%, increases the risk of cerebrovascular disorders in antihypertensive therapy. In patients with severe ICA stenosis, treatment with enalapril appears to be safer than that with isradipine.     

Continuous versus intermittent bladder irrigation of amphotericin B for the treatment of candiduria

PURPOSE: The efficacy of continuous versus intermittent bladder irrigation with amphotericin B in the treatment of candiduria was compared. MATERIALS AND METHODS: A prospective, randomized and comparative pilot study was done on 20 patients. Continuous bladder irrigation with 50 mg./l. amphotericin B infused during 24 hours for 2 days was compared to 3 intermittent bladder irrigations of 10 mg./100 ml. amphotericin B in 1 day. Urine cultures were obtained 72 hours after treatment. RESULTS: The organism was eradicated in 8 patients (80%) who received continuous irrigation and 3 (30%) who received intermittent irrigation (p = 0.035). CONCLUSIONS: Continuous amphotericin B bladder irrigation was superior in terms of efficacy, ease of administration and patient comfort.     

Comparative cost-effectiveness analysis of theophylline and ipratropium bromide in chronic obstructive pulmonary disease. A three-center study

The charts of 311 patients receiving theophylline (T) and 289 patients receiving ipratropium bromide (IB) for COPD were reviewed to determine the total costs and cost-effectiveness of these 2 agents in 3 different health-care settings. A direct cost-accounting method assessed cost, and a Markov decision-analysis model calculated cost-effectiveness. Costs to treat toxic effects were greater for T versus IB. The types and incidences of toxic effects, by drug, were similar among the three centers. Overall costs for T were $121.40 per patient per therapy-month versus $84.56 per patient per therapy-month for IB, as determined by the cost-accounting method. The marginal cost was $366 for T over IB when extrapolated over 1 year using the Markov model. The Markov model also predicted that patients receiving IB had a greater number of complication-free therapy-months (measurement of effectiveness) than patients receiving T. We conclude that treatment with IB was less costly and more cost-effective than T.     

Calculation of thermal stresses in thick-walled cylinders taking account of non-linear creep

Consideration is given to the solution for a long thick-walled cylinder in a temperature field, under a centrifugal force, axial force and internal-external pressure. It is propossed that the material of the cylinder deforms according to the non-linear theory of heredity. The problem is reduced to a system of two equations solved by an iterative method.     

Upper bounds for blocking probabilities in large multi‐rate loss networks

In this paper, we consider large loss networks with fixed routing and multirate traffic. We use singlelink formulae and standard results on multidimensional Gaussian distributions to obtain upper bounds for blocking probabilities of new calls under light up to critical loading conditions. This is the loading regime of interest for many practical applications such as admission control in ATM networks. The main advantage of our approach is that the complexity does not scale with the size of the system, making it numerically attractive. Comparison with simulation results show that we get good upper bounds. We conclude by discussing the correlation between links in a network.     

Accurate radiation boundary conditions for the time‐dependent wave equation on unbounded domains

Asymptotic and exact local radiation boundary conditions (RBC) for the scalar time‐dependent wave equation, first derived by Hagstrom and Hariharan, are reformulated as an auxiliary Cauchy problem for each radial harmonic on a spherical boundary. The reformulation is based on the hierarchy of local boundary operators used by Bayliss and Turkel which satisfy truncations of an asymptotic expansion for each radial harmonic. The residuals of the local operators are determined from the solution of parallel systems of linear first‐order temporal equations. A decomposition into orthogonal transverse modes on the spherical boundary is used so that the residual functions may be computed efficiently and concurrently without altering the local character of the finite element equations. Since the auxiliary functions are based on residuals of an asymptotic expansion, the proposed method has the ability to vary separately the radial and transverse modal orders of the RBC. With the number of equations in the auxiliary Cauchy problem equal to the transverse mode number, this reformulation is exact. In this form, the equivalence with the closely related non‐reflecting boundary condition of Grote and Keller is shown. If fewer equations are used, then the boundary conditions form high‐order accurate asymptotic approximations to the exact condition, with corresponding reduction in work and memory. Numerical studies are performed to assess the accuracy and convergence properties of the exact and asymptotic versions of the RBC. The results demonstrate that the asymptotic formulation has dramatically improved accuracy for time domain simulations compared to standard boundary treatments and improved efficiency over the exact condition. Copyright © 2000 John Wiley & Sons, Ltd.     

Concurrent Delays and Apportionment of Damages

This paper focuses on the subject of concurrent delay from a general contractor (GC)-subcontractor perspective. When there is a concurrent delay by multiple subcontractors, or between the GC and other subcontractor(s), there has not been a uniform approach as to how the liquidated damages are apportioned. Previous research seems to ignore this issue. This paper first reviews some relevant court cases. Using a warehouse project as a case study, it then examines different practices that the GC could take in apportioning damages of concurrent delays to both himself/herself as well as to the responsible subcontractors. Results are very inconsistent between and within the apportionment practices. This supports an alternative hypothesis that apportionment is an important issue. Practitioners should specify which apportionment practice will be used and under what circumstances it will be applied in their subcontracts. Researchers may develop a more consistent and reliable approach for this type of apportionment.     

Characterization of a novel dentin matrix acidic phosphoprotein. Implications for induction of biomineralization

Acidic phosphorylated proteins have been shown to be prominent constituents of the extracellular matrix of bone and dentin. The acidic phosphoproteins of bone contain more glutamic acid than aspartic acid and a lower serine content than either. On the other hand, the major dentin acidic phosphoproteins, phosphophoryns, have been defined as aspartic acid- and serine-rich proteins, with a lesser content of glutamic acid. Both sets of phosphoproteins have been implicated as key participants in regulating mineralization, but it has been difficult to unify their mechanisms of action. We have now identified, by cDNA cloning, a new serine-rich acidic protein of the dentin matrix, AG1, with a composition intermediate between the bone acidic proteins and dentin phosphophoryns. AG1 has numerous acidic consensus sites for phosphorylation by both casein kinases I and II. Immunochemical and organ culture biosynthetic studies show that AG1 is present in phosphorylated form at low levels in the dentin matrix. If fully phosphorylated, AG1 would bear a net charge of -175/molecule of 473 residues. AG1 contains single RGD integrin binding and N-glycosylation sequences. The overall picture that emerges is that of a matrix-associated acidic phosphoprotein, with a potentially high calcium ion binding capacity, present at levels compatible with a regulatory role in dentin mineralization.